San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message ACEBUTOLOL HCL ACEBUTOLOL 200MG CAPS None None 180 30 HYDROCHLORIDE ACETAMINOPHEN/CODEINE #2 ACETAMINOPHEN; CODEINE 300MG; 15MG TABS None None 120 30 PHOSPHATE ACETAMINOPHEN/CODEINE #3 ACETAMINOPHEN; CODEINE 300MG; 30MG TABS None None 120 30 PHOSPHATE ACETAMINOPHEN/CODEINE ACETAMINOPHEN; CODEINE 300MG; 60MG TABS None None 120 30 PHOSPHATE HYDROCODONE/ACETAMINOPHE ACETAMINOPHEN; 325MG; 5MG TABS None None 120 30 N HYDROCODONE BITARTRATE

HYDROCODONE/ACETAMINOPHE ACETAMINOPHEN; 325MG; 7.5MG TABS None None 120 30 N HYDROCODONE BITARTRATE

HYDROCODONE/ACETAMINOPHE ACETAMINOPHEN; 325MG; 10MG TABS None None 120 30 N HYDROCODONE BITARTRATE

OXYCODONE/ACETAMINOPHEN ACETAMINOPHEN; 325MG; 5MG TABS None None 120 30 OXYCODONE HYDROCHLORIDE ACETAZOLAMIDE ER ACETAZOLAMIDE 500MG CP12 Min Age: 21Y None AGE 0-21 BILL CCS ACETAZOLAMIDE ACETAZOLAMIDE 125MG TABS Min Age: 21Y None AGE 0-21 BILL CCS ACETAZOLAMIDE ACETAZOLAMIDE 250MG TABS Min Age: 21Y None AGE 0-21 BILL CCS TUDORZA PRESSAIR ACLIDINIUM BROMIDE 400MCG/ACT AEPB None None 1 30 ACYCLOVIR ACYCLOVIR 800MG TABS None None 150 30 ACYCLOVIR ACYCLOVIR 400MG TABS None None 150 30 ACYCLOVIR ACYCLOVIR 200MG CAPS None None 150 30 ADAPALENE 0.1% GEL Max Age: 30Y None 45 30 Use

ADAPALENE ADAPALENE 0.1% CREA Max Age: 30Y None 45 30 Use tretinoin & adapalene gel ADAPALENE ADAPALENE 0.3% GEL None 45 30 PA Required ADAPALENE ADAPALENE 0.3% GEL None None 45 30 PA Required ALBENZA ALBENDAZOLE 200MG TABS None None 4 30 Max 2 fills per year ALBUTEROL SULFATE ALBUTEROL SULFATE 2MG TABS None None 120 30 ALBUTEROL SULFATE ALBUTEROL SULFATE 4MG TABS None None 120 30 ALBUTEROL SULFATE ALBUTEROL SULFATE 2MG/5ML SYRP Max Age: 5 Y None 120 30 VENTOLIN HFA ALBUTEROL SULFATE 108MCG/ACT AERS None None 36 30 ALBUTEROL SULFATE ALBUTEROL SULFATE 0.5% NEBU None None 100 30 ALBUTEROL SULFATE ALBUTEROL SULFATE 0.083% NEBU None None 525 30 IPRATROPIUM ALBUTEROL SULFATE; 2.5MG/3ML; 0.5MG/3ML SOLN None None 570 30 BROMIDE/ALBUTEROL SULFATE IPRATROPIUM BROMIDE

COMBIVENT RESPIMAT ALBUTEROL SULFATE; 100MCG/ACT; 20MCG/ACT AERS None None 4 20 IPRATROPIUM BROMIDE

Page 1 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message ALENDRONATE SODIUM ALENDRONATE SODIUM 35MG TABS Min Age: 50Y None 4 30 AGE 0-21 BILL CCS BINOSTO ALENDRONATE SODIUM 70MG TBEF Min Age: 50Y None 4 30 AGE 0-21 BILL CCS ALENDRONATE SODIUM ALENDRONATE SODIUM 70MG/75ML SOLN Min Age: 50 None PA Required. For members age 0-21 BILL CCS ALENDRONATE SODIUM ALENDRONATE SODIUM 10MG TABS Min Age: 50Y None PA Required. For members age 0-21 BILL CCS ALENDRONATE SODIUM ALENDRONATE SODIUM 40MG TABS Min Age: 50Y None PA Required. For members age 0-21 BILL CCS ALENDRONATE SODIUM ALENDRONATE SODIUM 5MG TABS Min Age: 50Y None PA Required. For members age 0-21 BILL CCS ALENDRONATE SODIUM ALENDRONATE SODIUM 70MG TABS Min Age: 50Y None AGE 0-21 BILL CCS FOSAMAX PLUS D ALENDRONATE SODIUM; 70MG; 2800UNIT TABS Min Age: 50Y None PA Required. CHOLECALCIFEROL For members age 0-21 BILL CCS FOSAMAX PLUS D ALENDRONATE SODIUM; 70MG; 5600UNIT TABS Min Age: 50Y None PA Required. CHOLECALCIFEROL For members age 0-21 BILL CCS CITRANATAL HARMONY ALGAL OIL (); CALCIUM 650MG; 104MG; 400UNIT; CAPS None Female 30 30 CITRATE; 265MG; 50MG; 1MG; 29MG; CHOLECALCIFEROL; 25MG; 30UNIT DOCOSAHEXAENOIC ACID (DHA) (); DOCUSATE SODIUM; FOLIC ACID; IRON CARBONYL; PYRIDOXINE HYDROCHLORIDE; TOCOPHERYL ACET,DL-ALPHA ALLOPURINOL ALLOPURINOL 100MG TABS None None 240 30 ALLOPURINOL ALLOPURINOL 300MG TABS None None 60 30 AXERT ALMOTRIPTAN MALATE 12.5MG TABS Min Age: 12Y None Use sumatriptan tabs

AXERT ALMOTRIPTAN MALATE 6.25MG TABS Min Age: 12Y None Use sumatriptan tabs

HYPERCARE ALUMINUM CHLORIDE 20% SOLN None None 35 30

Page 2 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message AMIODARONE HCL AMIODARONE HCL 200MG TABS Min Age: 21Y None AGE 0-21 BILL CCS AMIODARONE HCL AMIODARONE HCL 400MG TABS Min Age: 21Y None AGE 0-21 BILL CCS AMLODIPINE BESYLATE AMLODIPINE BESYLATE 2.5MG TABS Min Age: 21Y None AGE 0-21 BILL CCS AMLODIPINE BESYLATE AMLODIPINE BESYLATE 10MG TABS Min Age: 21Y None AGE 0-21 BILL CCS AMLODIPINE BESYLATE AMLODIPINE BESYLATE 5MG TABS Min Age: 21Y None AGE 0-21 BILL CCS AMPHETAMINE/DEXTROAMPHET AMPHETAMINE ASPARTATE; 1.875MG; 1.875MG; 1.875MG; TABS Min Age: 5Y None 60 30 AMINE AMPHETAMINE SULFATE; 1.875MG Max Age: 18Y DEXTROAMPHETAMINE SACCHARATE; DEXTROAMPHETAMINE SULFATE

AMPHETAMINE/DEXTROAMPHET AMPHETAMINE ASPARTATE; 3.125MG; 3.125MG; 3.125MG; TABS Min Age: 5Y None 60 30 AMINE AMPHETAMINE SULFATE; 3.125MG Max Age: 18Y DEXTROAMPHETAMINE SACCHARATE; DEXTROAMPHETAMINE SULFATE

AMPHETAMINE/DEXTROAMPHET AMPHETAMINE ASPARTATE; 3.75MG; 3.75MG; 3.75MG; TABS Min Age: 5Y None 60 30 AMINE AMPHETAMINE SULFATE; 3.75MG Max Age: 18Y DEXTROAMPHETAMINE SACCHARATE; DEXTROAMPHETAMINE SULFATE

AMPHETAMINE/DEXTROAMPHET AMPHETAMINE ASPARTATE; 1.25MG; 1.25MG; 1.25MG; TABS Min Age: 5Y None 60 30 AMINE AMPHETAMINE SULFATE; 1.25MG Max Age: 18Y DEXTROAMPHETAMINE SACCHARATE; DEXTROAMPHETAMINE SULFATE

AMPHETAMINE/DEXTROAMPHET AMPHETAMINE ASPARTATE; 2.5MG; 2.5MG; 2.5MG; 2.5MG TABS Min Age: 5Y None 60 30 AMINE AMPHETAMINE SULFATE; Max Age: 18Y DEXTROAMPHETAMINE SACCHARATE; DEXTROAMPHETAMINE SULFATE

Page 3 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message AMPHETAMINE/DEXTROAMPHET AMPHETAMINE ASPARTATE; 7.5MG; 7.5MG; 7.5MG; 7.5MG TABS Min Age: 5Y None 60 30 AMINE AMPHETAMINE SULFATE; Max Age: 18Y DEXTROAMPHETAMINE SACCHARATE; DEXTROAMPHETAMINE SULFATE

AMPHETAMINE/DEXTROAMPHET AMPHETAMINE ASPARTATE; 5MG; 5MG; 5MG; 5MG TABS Min Age: 5Y None 60 30 AMINE AMPHETAMINE SULFATE; Max Age: 18Y DEXTROAMPHETAMINE SACCHARATE; DEXTROAMPHETAMINE SULFATE

AMPICILLIN AMPICILLIN 125MG/5ML SUSR None None 200 10 AMPICILLIN AMPICILLIN 250MG/5ML SUSR None None 200 10 CREON AMYLASE (DIASTASE); 30000UNIT; 6000UNIT; CPEP Min Age: 21Y None 150 30 AGE 0-21 BILL LIPASE (AS PANCRELIPASE); 19000UNIT CCS PROTEASE

CREON AMYLASE (DIASTASE); 60000UNIT; 12000UNIT; CPEP Min Age: 21Y None 150 30 AGE 0-21 BILL LIPASE (AS PANCRELIPASE); 38000UNIT CCS PROTEASE

CREON AMYLASE (DIASTASE); 120000UNIT; 24000UNIT; CPEP Min Age: 21Y None 150 30 AGE 0-21 BILL LIPASE (AS PANCRELIPASE); 76000UNIT CCS PROTEASE

ZENPEP AMYLASE (DIASTASE); 27000UNIT; 5000UNIT; CPEP Min Age: 21Y None 150 30 AGE 0-21 BILL LIPASE (AS PANCRELIPASE); 17000UNIT CCS PROTEASE

ZENPEP AMYLASE (DIASTASE); 55000UNIT; 10000UNIT; CPEP Min Age: 21Y None 150 30 AGE 0-21 BILL LIPASE (AS PANCRELIPASE); 34000UNIT CCS PROTEASE

ZENPEP AMYLASE (DIASTASE); 82000UNIT; 15000UNIT; CPEP Min Age: 21Y None 150 30 AGE 0-21 BILL LIPASE (AS PANCRELIPASE); 51000UNIT CCS PROTEASE

ZENPEP AMYLASE (DIASTASE); 109000UNIT; 20000UNIT; CPEP Min Age: 21Y None 150 30 AGE 0-21 BILL LIPASE (AS PANCRELIPASE); 68000UNIT CCS PROTEASE

CREON AMYLASE (DIASTASE); 15000UNIT; 3000UNIT; CPEP Min Age: 21Y None 150 30 AGE 0-21 BILL LIPASE (AS PANCRELIPASE); 9500UNIT CCS PROTEASE

Page 4 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message ZENPEP AMYLASE (DIASTASE); 16000UNIT; 3000UNIT; CPEP Min Age: 21Y None 150 30 AGE 0-21 BILL LIPASE (AS PANCRELIPASE); 10000UNIT CCS PROTEASE

ZENPEP AMYLASE (DIASTASE); 136000UNIT; 25000UNIT; CPEP Min Age: 21Y None 150 30 AGE 0-21 BILL LIPASE (AS PANCRELIPASE); 85000UNIT CCS PROTEASE

ANASTROZOLE ANASTROZOLE 1MG TABS None None 30 30 PRENATAL ASCORBIC ACID; ASCORBYL 100MG; 0; 0; 263MG; TABS None Female 30 30 PALMITATE; BETA 400UNIT; 4MCG; 27MG; CAROTENE; CALCIUM; 0.8MG; 18MG; 2.6MG; 1.7MG; CHOLECALCIFEROL; 1.5MG; 11UNIT; 4000UNIT; CYANOCOBALAMIN; FERROUS 25MG FUMARATE; FOLIC ACID; NIACINAMIDE; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; THIAMINE MONONITRATE; TOCOPHERYL ACET,DL- ALPHA; ACETATE (RETINYL ACETATE); ZINC OXIDE

Page 5 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message PROTECTNATAL ASCORBIC ACID; BETA 125MG; 0; 25MCG; 12.5MG; TBEC None Female 60 30 CAROTENE; BIOTIN; 150MG; 12.5MG; 200UNIT; BROMELAINS; CALCIUM; 25MCG; 15MG; 0.5MG; CALCIUM PANTOTHENATE; 100MCG; 75MG; 112MG; CHOLECALCIFEROL; 700MG; 0.5MG; 50MG; 1MG; CHROMIUM AMINO ACID 25MCG; 10MG; 12.5MG; CHELATE; COENZYME Q10 13.5MG; 5MCG; 5MG; 5MG; (UBIDECARENONE); COPPER 37.5MCG; 5MG; 1250UNIT; AMINO ACID CHELATE; 25UNIT; 50MG; 7.5MG CYANOCOBALAMIN; DOCOSAHEXAENOIC ACID (DHA); (EPA); ; FOLIC ACID; MAGNESIUM; MANGANESE AMINO ACID CHELATE; MOLYBDENUM AMINO ACID CHELATE; NIACIN; PAPAYA; POLYSACCHARIDE IRON; POTASSIUM IODIDE; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; SELENIUM AMINO ACID CHELATE; THIAMINE HYDROCHLORIDE; VITAMIN A; VITAMIN E ACETATE (D-ALPHA); WHEY; ZINC AMINO ACID CHELATE

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Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message THERANATAL COMPLETE ASCORBIC ACID; BETA 100MG; 3000UNIT; 30MCG; MISC None Female 60 30 CAROTENE; BIOTIN; 140MG; 6MG; 3000UNIT; CALCIUM CARBONATE; 200MG; 30MCG; 2MG; CALCIUM PANTOTHENATE; 12MCG; 30UNIT; 300MG; CHOLECALCIFEROL; CHOLINE 27MG; 1MG; 50MG; 20MG; BITARTRATE; CHROMIUM 220MCG; 30MG; 1.7MG; AMINO ACID CHELATE; 70MCG; 50MCG; 1.5MG; 15MG CUPRIC OXIDE; CYANOCOBALAMIN; D-ALPHA- TOCOPHERYL ACID SUCCINATE; DOCOSAHEXAENOIC ACID (DHA); FERROUS FUMARATE; FOLIC ACID; MAGNESIUM OXIDE; NIACINAMIDE; POTASSIUM IODIDE; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; SELENIUM AMINO ACID CHELATE; SODIUM MOLYBDATE; THIAMINE MONONITRATE; VINATE AZ ASCORBIC ACID; BETA 120MG; 3000UNIT; 30MCG; TABS None Female 30 30 CAROTENE; BIOTIN; 150MG; 8MG; 400UNIT; CALCIUM CARBONATE; 2.5MG; 12MCG; 27MG; 1MG; CALCIUM PANTOTHENATE; 75MG; 20MG; 30MG; 3.5MG; CHOLECALCIFEROL; CUPRIC 3MG; 30UNIT; 15MG OXIDE; CYANOCOBALAMIN; FERROUS BISGLYCINATE CHELATE; FOLIC ACID; MAGNESIUM OXIDE; NIACINAMIDE; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; THIAMINE HYDROCHLORIDE; TOCOPHERYL ACET,DL- ALPHA; ZINC OXIDE

Page 7 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message PRENATE ELITE ASCORBIC ACID; BETA 75MG; 2600UNIT; 330MCG; TABS None Female 30 30 CAROTENE; BIOTIN; 100MG; 6MG; 450UNIT; CALCIUM CARBONATE; 1.5MG; 13MCG; 26MG; CALCIUM PANTOTHENATE; 400MCG; 150MCG; 600MCG; CHOLECALCIFEROL; CUPRIC 25MG; 21MG; 21MG; 3.5MG; OXIDE; CYANOCOBALAMIN; 3MG; 10UNIT; 15MG FERROUS FUMARATE; FOLIC ACID; ; LEVOMEFOLATE GLUCOSAMINE (QUATREFOLIC); MAGNESIUM OXIDE; NIACINAMIDE; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; THIAMINE MONONITRATE; TOCOPHERYL ACET,DL- ALPHA; ZINC OXIDE

ZATEAN-PN ASCORBIC ACID; BETA 80MG; 2500UNIT; 300MCG; TABS None Female 30 30 CAROTENE; BIOTIN; 120MG; 6MG; 400UNIT; 2MG; CALCIUM CARBONATE; 12MCG; 27MG; 400MCG; CALCIUM PANTOTHENATE; 600MCG; 30MG; 20MG; CHOLECALCIFEROL; CUPRIC 150MCG; 20MG; 3.4MG; 3MG; OXIDE; CYANOCOBALAMIN; 10UNIT; 15MG FERROUS FUMARATE; FOLIC ACID; L-METHYLFOLATE; MAGNESIUM OXIDE; NIACINAMIDE; POTASSIUM IODIDE; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; THIAMINE MONONITRATE; TOCOPHERYL ACET,DL- ALPHA; ZINC OXIDE

Page 8 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message TRINATAL GT ASCORBIC ACID; BETA 120MG; 2700UNIT; 30MCG; TABS None Female 30 30 CAROTENE; BIOTIN; 200MG; 400UNIT; 2MG; CALCIUM CARBONATE; 12MCG; 50MG; 1MG; 90MG; CHOLECALCIFEROL; CUPRIC 30MG; 20MG; 6MG; 20MG; OXIDE; CYANOCOBALAMIN; 3.4MG; 3MG; 10UNIT; 15MG DOCUSATE SODIUM; FOLIC ACID; IRON CARBONYL; MAGNESIUM OXIDE; NIACINAMIDE; PANTOTHENIC ACID; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; THIAMINE MONONITRATE; TOCOPHERYL ACET,DL- ALPHA; ZINC OXIDE ATABEX EC ASCORBIC ACID; BETA 120MG; 0; 30MCG; 100MG; TBEC None Female 30 30 CAROTENE; BIOTIN; 400UNIT; 1.6MG; 12MCG; CALCIUM CARBONATE; 50MG; 1MG; 29MG; 20MG; CHOLECALCIFEROL; CUPRIC 20MG; 30MG; 3MG; 1.5MG; OXIDE; CYANOCOBALAMIN; 30UNIT; 2500UNIT; 20MG DOCUSATE SODIUM; FOLIC ACID; IRON CARBONYL; MAGNESIUM OXIDE; NIACINAMIDE; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; THIAMINE; TOCOPHERYL ACET,DL- ALPHA; VITAMIN A; ZINC OXIDE

Page 9 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message CENTRUM SPECIALIST ASCORBIC ACID; BETA 90MG; 0; 30MCG; 250MG; MISC None Female 60 30 PRENATAL CAROTENE; BIOTIN; 6MG; 72MG; 400UNIT; CALCIUM; CALCIUM 30MCG; 0.9MG; 2.6MCG; PANTOTHENATE; CHLORIDE 200MG; 15MG; 27MG; 0; ION; CHOLECALCIFEROL; 800MCG; 50MG; 2MG; 18MG; CHROMIC CHLORIDE; CUPRIC 20MG; 30MCG; 80MG; SULFATE ANHYDROUS; 220MCG; 1.9MG; 1.4MG; CYANOCOBALAMIN; 50MCG; 30MCG; 1.4MG; DOCOSAHEXAENOIC ACID 35UNIT; 2500UNIT; 11MG (DHA); EICOSAPENTAENOIC ACID (EPA); FERROUS FUMARATE; FISH OIL; FOLIC ACID; MAGNESIUM; MANGANESE SULFATE; NIACINAMIDE; PHOSPHORUS; PHYTONADIONE; POTASSIUM; POTASSIUM IODIDE; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; SODIUM MOLYBDATE; SODIUM SELENATE; THIAMINE MONONITRATE; TOCOPHERYL ACET,DL- ALPHA; VITAMIN A ACETATE (RETINYL ACETATE); ZINC OXIDE

Page 10 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message ONE-A-DAY WOMENS PRENATAL ASCORBIC ACID; BETA 60MG; 0; 300MCG; 300MG; MISC None None 60 30 CAROTENE; BIOTIN; 10MG; 400UNIT; 2MG; 8MCG; CALCIUM; CALCIUM 200MG; 240MG; 28MG; PANTOTHENATE; 800MCG; 50MG; 20MG; CHOLECALCIFEROL; CUPRIC 440MG; 150MCG; 2.5MG; OXIDE; CYANOCOBALAMIN; 2MG; 1.7MG; 30UNIT; DOCOSAHEXAENOIC ACID 4000UNIT; 15MG (DHA); EICOSAPENTAENOIC ACID (EPA); FERROUS FUMARATE; FOLIC ACID; MAGNESIUM OXIDE; NIACINAMIDE; OMEGA-3 FATTY ACIDS; POTASSIUM IODIDE; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; THIAMINE MONONITRATE; TOCOPHERYL ACET,DL- ALPHA; VITAMIN A ACETATE (RETINYL ACETATE); ZINC OXIDE CENTRUM KIDS COMPLETE ASCORBIC ACID; BETA 60MG; 0; 45MCG; 108MG; CHEW Max Age: 12Y None CAROTENE; BIOTIN; 10MG; 20MCG; 2MG; 6MCG; CALCIUM; CALCIUM 400UNIT; 400MCG; 18MG; PANTOTHENATE; CHROMIC 40MG; 1MG; 20MG; 50MG; CHLORIDE; CUPRIC OXIDE; 10MCG; 150MCG; 2MG; CYANOCOBALAMIN; 1.7MG; 20MCG; 1.5MG; ERGOCALCIFEROL; FOLIC 30UNIT; 3500UNIT; 15MG ACID; IRON CARBONYL; MAGNESIUM; MANGANESE SULFATE; NIACINAMIDE; PHOSPHORUS; PHYTONADIONE; POTASSIUM IODIDE; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; SODIUM MOLYBDATE; THIAMINE MONONITRATE; TOCOPHERYL ACET,DL- ALPHA; VITAMIN A ACETATE (RETINYL ACETATE); ZINC OXIDE

Page 11 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message VINATE ONE ASCORBIC ACID; BETA 80MG; 0; 0.03MG; 200MG; TABS None Female 30 30 CAROTENE; BIOTIN; 400UNIT; 3MG; 2.5MCG; CALCIUM; 60MG; 1MG; 100MG; 17MG; CHOLECALCIFEROL; CUPRIC 7MG; 4MG; 1.6MG; 1.5MG; OXIDE; CYANOCOBALAMIN; 15UNIT; 4000UNIT; 25MG FERROUS FUMARATE; FOLIC ACID; MAGNESIUM; NIACINAMIDE; PANTOTHENIC ACID; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; THIAMINE MONONITRATE; TOCOPHERYL ACET,DL- ALPHA; VITAMIN A ACETATE (RETINYL ACETATE); ZINC OXIDE TRIVEEN-TEN ASCORBIC ACID; BETA 30MG; 1250UNIT; 0; TABS None Female 60 30 CAROTENE; CALCIUM 120UNIT; 50MG; 1MG; 1MCG; ASCORBATE ANHYDROUS; 50MG; 0.5MG; 15MG; 5MG; CHOLECALCIFEROL; 10MG; 1.7MG; 0; 7.5MCG; COENZYME Q10 1MG; 15UNIT; 12.5MG (UBIDECARENONE); CUPRIC OXIDE; CYANOCOBALAMIN; DOCOSAHEXAENOIC ACID (DHA); FOLIC ACID; IRON CARBONYL; LYCOPENE; MAGNESIUM OXIDE; RIBOFLAVIN; SODIUM ASCORBATE; SODIUM SELENATE; THIAMINE MONONITRATE; VITAMIN E; ZINC OXIDE

Page 12 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message PERRY PRENATAL ASCORBIC ACID; BETA 50MG; 0; 100MG; 5MG; CAPS None Female 30 30 CAROTENE; CALCIUM 200UNIT; 1MG; 4MCG; CARBONATE; CALCIUM 13.5MG; 400MCG; 50MG; PANTOTHENATE; 10MG; 75MCG; 2MG; 1MG; CHOLECALCIFEROL; CUPRIC 1.5MG; 15UNIT; 3000UNIT; OXIDE; CYANOCOBALAMIN; 7.5MG FERROUS FUMARATE; FOLIC ACID; MAGNESIUM OXIDE; NIACINAMIDE; POTASSIUM IODIDE; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; THIAMINE MONONITRATE; TOCOPHERYL ACET,DL- ALPHA; VITAMIN A ACETATE (RETINYL ACETATE); ZINC CITRATE

PRENATAL 19 ASCORBIC ACID; BETA 100MG; 1000UNIT; 200MG; CHEW None Female 30 30 CAROTENE; CALCIUM 7MG; 12MCG; 25MG; 29MG; CARBONATE; CALCIUM 1MG; 6MG; 20MG; 3MG; PANTOTHENATE; 3MG; 400UNIT; 30UNIT; CYANOCOBALAMIN; 20MG DOCUSATE SODIUM; FERROUS FUMARATE; FOLIC ACID; NIACINAMIDE; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; THIAMINE MONONITRATE; VITAMIN D; VITAMIN E ACETATE (D- ALPHA); ZINC OXIDE VITAFOL-OB ASCORBIC ACID; BETA 70MG; 2700UNIT; 100MG; TABS None Female 30 30 CAROTENE; CALCIUM 400UNIT; 2MG; 12MCG; CARBONATE; 65MG; 1MG; 25MG; 18MG; CHOLECALCIFEROL; COPPER; 2.5MG; 1.8MG; 1.6MG; CYANOCOBALAMIN; FERROUS 30UNIT; 25MG FUMARATE; FOLIC ACID; MAGNESIUM OXIDE; NIACINAMIDE; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; THIAMINE MONONITRATE; TOCOPHERYL ACET,DL- ALPHA; ZINC OXIDE

Page 13 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message CAVAN-EC SOD DHA ASCORBIC ACID; BETA 130MG; 3000UNIT; 230MG; MISC None Female 60 30 CAROTENE; CALCIUM 410UNIT; 2MG; 12MCG; CARBONATE; 295MG; 0; 0; 628MG; 1MG; CHOLECALCIFEROL; CUPRIC 25MG; 20MG; 440MG; 28MG; OXIDE; CYANOCOBALAMIN; 4MG; 30MG; 1.8MG; 30MG; DOCOSAHEXAENOIC ACID 26MG (DHA); (DPA); EICOSAPENTAENOIC ACID (EPA); FISH OIL; FOLIC ACID; MAGNESIUM OXIDE; NIACINAMIDE; OMEGA-3 FATTY ACIDS; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; SODIUM FEREDETATE (FERRAZONE); THIAMINE MONONITRATE; TOCOPHERYL ACET,DL- ALPHA; ZINC OXIDE

DUET DHA BALANCED ASCORBIC ACID; BETA 120MG; 2840UNIT; 215MG; MISC None Female 60 30 CAROTENE; CALCIUM 840UNIT; 2MG; 12MCG; 0; 0; CARBONATE; 0; 1MG; 210MCG; 26MG; 0; CHOLECALCIFEROL; CUPRIC 25MG; 20MG; 278MG; 0; OXIDE; CYANOCOBALAMIN; 50MG; 4MG; 0; 1.5MG; 2MG; DOCOSAHEXAENOIC ACID 25MG (DHA); DOCOSAPENTAENOIC ACID (DPA); EICOSAPENTAENOIC ACID (EPA); FOLIC ACID; IODINE; IRON; LINOLENIC ACID; MAGNESIUM OXIDE; NIACINAMIDE; OMEGA-3 FATTY ACIDS; POLYSACCHARIDE IRON COMPLEX; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; SODIUM FEREDETATE (FERRAZONE); THIAMINE MONONITRATE; VITAMIN E ACETATE (D- ALPHA); ZINC OXIDE

Page 14 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message DUET DHA BALANCED ASCORBIC ACID; BETA 120MG; 2850UNIT; 219MG; MISC None Female 60 30 CAROTENE; CALCIUM 840UNIT; 2MG; 12MCG; 0; 0; CARBONATE; 0; 1MG; 220MCG; 27MG; CHOLECALCIFEROL; CUPRIC 25MG; 20MG; 380MG; 0; OXIDE; CYANOCOBALAMIN; 50MG; 4MG; 0; 0; 1.8MG; DOCOSAHEXAENOIC ACID 3MG; 25MG (DHA); DOCOSAPENTAENOIC ACID (DPA); EICOSAPENTAENOIC ACID (EPA); FOLIC ACID; IODINE; IRON; MAGNESIUM OXIDE; NIACINAMIDE; OMEGA-3 FATTY ACIDS; POLYSACCHARIDE IRON COMPLEX; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; SODIUM ASCORBATE; SODIUM FEREDETATE (FERRAZONE); THIAMINE MONONITRATE; TOCOPHERYL ACET,DL- ALPHA; ZINC OXIDE

PR NATAL 430 EC ASCORBIC ACID; BETA 120MG; 3000UNIT; 200MG; MISC None Female 60 30 CAROTENE; CALCIUM 400UNIT; 2MG; 12MCG; CARBONATE; 295MG; 0; 0; 1MG; 29MG; 0; CHOLECALCIFEROL; CUPRIC 25MG; 20MG; 430MG; 25MG; OXIDE; CYANOCOBALAMIN; 4MG; 1.8MG; 3MG; 25MG DOCOSAHEXAENOIC ACID (DHA); EICOSAPENTAENOIC ACID (EPA); FERROUS BISGLYCINATE CHELATE; FOLIC ACID; IRON; IRON PROTEIN SUCCINYLATE; MAGNESIUM OXIDE; NIACINAMIDE; OMEGA-3 FATTY ACIDS; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; THIAMINE MONONITRATE; TOCOPHERYL ACET,DL- ALPHA; ZINC OXIDE

Page 15 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message PR NATAL 430 ASCORBIC ACID; BETA 120MG; 3000UNIT; 200MG; MISC None Female 60 30 CAROTENE; CALCIUM 400UNIT; 2MG; 12MCG; CARBONATE; 295MG; 0; 0; 1MG; 29MG; 0; CHOLECALCIFEROL; CUPRIC 25MG; 20MG; 430MG; 25MG; OXIDE; CYANOCOBALAMIN; 4MG; 1.8MG; 30MG; 25MG DOCOSAHEXAENOIC ACID (DHA); EICOSAPENTAENOIC ACID (EPA); FERROUS BISGLYCINATE; FOLIC ACID; IRON; IRON PROTEIN SUCCINYLATE; MAGNESIUM OXIDE; NIACINAMIDE; OMEGA-3 FATTY ACIDS; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; THIAMINE HYDROCHLORIDE; TOCOPHERYL ACET,DL- ALPHA; ZINC OXIDE

PR NATAL 400 ASCORBIC ACID; BETA 120MG; 3000UNIT; 200MG; MISC None Female 60 30 CAROTENE; CALCIUM 400UNIT; 2MG; 12MCG; CARBONATE; 275MG; 0; 0; 1MG; 29MG; 0; CHOLECALCIFEROL; CUPRIC 25MG; 20MG; 400MG; 25MG; OXIDE; CYANOCOBALAMIN; 4MG; 1.8MG; 30MG; 25MG DOCOSAHEXAENOIC ACID (DHA); EICOSAPENTAENOIC ACID (EPA); FERROUS BISGLYCINATE; FOLIC ACID; IRON; IRON PROTEIN SUCCINYLATE; MAGNESIUM OXIDE; NIACINAMIDE; OMEGA-3 FATTY ACIDS; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; THIAMINE MONONITRATE; TOCOPHERYL ACET,DL- ALPHA; ZINC OXIDE

Page 16 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message BAL-CARE DHA ASCORBIC ACID; BETA 120MG; 2850UNIT; 219MG; MISC None Female 60 30 CAROTENE; CALCIUM 840UNIT; 2MG; 12MCG; CARBONATE; 295MG; 0; 1MG; 220MCG; CHOLECALCIFEROL; CUPRIC 27MG; 25MG; 20MG; 430MG; OXIDE; CYANOCOBALAMIN; 0; 50MG; 4MG; 0; 1.8MG; DOCOSAHEXAENOIC ACID 3MG; 25MG (DHA); EICOSAPENTAENOIC ACID (EPA); FOLIC ACID; IODINE; IRON; MAGNESIUM OXIDE; NIACINAMIDE; OMEGA-3 FATTY ACIDS; POLYSACCHARIDE IRON COMPLEX; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; SODIUM FEREDETATE (FERRAZONE); THIAMINE MONONITRATE; TOCOPHERYL ACET,DL- ALPHA; ZINC OXIDE

DUET DHA 400 ASCORBIC ACID; BETA 120MG; 2800UNIT; 200MG; MISC None Female 60 30 CAROTENE; CALCIUM 820UNIT; 2MG; 12MCG; 0; 0; CARBONATE; 1MG; 220MCG; 25MG; 25MG; CHOLECALCIFEROL; CUPRIC 20MG; 400MG; 0; 50MG; OXIDE; CYANOCOBALAMIN; 4MG; 0; 1.8MG; 3MG; 25MG DOCOSAHEXAENOIC ACID (DHA); EICOSAPENTAENOIC ACID (EPA); FOLIC ACID; IODINE; IRON; MAGNESIUM OXIDE; NIACINAMIDE; OMEGA-3 FATTY ACIDS; POLYSACCHARIDE IRON COMPLEX; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; SODIUM FEREDETATE (FERRAZONE); THIAMINE MONONITRATE; VITAMIN E ACETATE (D- ALPHA); ZINC OXIDE

Page 17 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message DUET DHA 430 ASCORBIC ACID; BETA 120MG; 2800UNIT; 200MG; MISC None Female 60 30 CAROTENE; CALCIUM 820UNIT; 2MG; 12MCG; 0; 0; CARBONATE; 1MG; 220MCG; 25MG; 25MG; CHOLECALCIFEROL; CUPRIC 20MG; 430MG; 0; 50MG; OXIDE; CYANOCOBALAMIN; 4MG; 0; 1.8MG; 3MG; 25MG DOCOSAHEXAENOIC ACID (DHA); EICOSAPENTAENOIC ACID (EPA); FOLIC ACID; IODINE; IRON; MAGNESIUM OXIDE; NIACINAMIDE; OMEGA-3 FATTY ACIDS; POLYSACCHARIDE IRON COMPLEX; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; SODIUM FEREDETATE (FERRAZONE); THIAMINE MONONITRATE; VITAMIN E ACETATE (D- ALPHA); ZINC OXIDE

DUET DHA 400EC ASCORBIC ACID; BETA 120MG; 2825UNIT; 200MG; MISC None Female 60 30 CAROTENE; CALCIUM 800UNIT; 2MG; 12MCG; 0; 0; CARBONATE; 1MG; 220MCG; 25MG; 25MG; CHOLECALCIFEROL; CUPRIC 20MG; 400MG; 0; 45MG; OXIDE; CYANOCOBALAMIN; 4MG; 0; 1.8MG; 3MG; 25MG DOCOSAHEXAENOIC ACID (DHA); EICOSAPENTAENOIC ACID (EPA); FOLIC ACID; IODINE; IRON; MAGNESIUM OXIDE; NIACINAMIDE; OMEGA-3 FATTY ACIDS; POLYSACCHARIDE IRON COMPLEX; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; SODIUM FEREDETATE (FERRAZONE); THIAMINE MONONITRATE; VITAMIN E ACETATE (D- ALPHA); ZINC OXIDE

Page 18 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message DUET DHA 430EC ASCORBIC ACID; BETA 120MG; 2825UNIT; 200MG; MISC None Female 60 30 CAROTENE; CALCIUM 800UNIT; 2MG; 12MCG; 0; 0; CARBONATE; 1MG; 220MCG; 25MG; 25MG; CHOLECALCIFEROL; CUPRIC 20MG; 430MG; 0; 45MG; OXIDE; CYANOCOBALAMIN; 4MG; 0; 1.8MG; 3MG; 25MG DOCOSAHEXAENOIC ACID (DHA); EICOSAPENTAENOIC ACID (EPA); FOLIC ACID; IODINE; IRON; MAGNESIUM OXIDE; NIACINAMIDE; OMEGA-3 FATTY ACIDS; POLYSACCHARIDE IRON COMPLEX; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; SODIUM FEREDETATE (FERRAZONE); THIAMINE MONONITRATE; VITAMIN E ACETATE (D- ALPHA); ZINC OXIDE

PR NATAL 400 EC ASCORBIC ACID; BETA 120MG; 3000UNIT; 200MG; MISC None Female 60 30 CAROTENE; CALCIUM 400UNIT; 2MG; 12MCG; CARBONATE; 275MG; 0; 1MG; 29MG; CHOLECALCIFEROL; CUPRIC 25MG; 20MG; 400MG; 25MG; OXIDE; CYANOCOBALAMIN; 4MG; 1.8MG; 3MG; 25MG DOCOSAHEXAENOIC ACID (DHA); EICOSAPENTAENOIC ACID (EPA); FOLIC ACID; IRON; MAGNESIUM OXIDE; NIACINAMIDE; OMEGA-3 FATTY ACIDS; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; THIAMINE HYDROCHLORIDE; TOCOPHERYL ACET,DL- ALPHA; ZINC OXIDE

Page 19 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message COMPLETE NATAL DHA ASCORBIC ACID; BETA 120MG; 0; 200MG; 400UNIT; MISC None Female 60 30 CAROTENE; CALCIUM 2MG; 12MCG; 200MG; 0; CARBONATE; 1MG; 29MG; 0; 25MG; 20MG; CHOLECALCIFEROL; CUPRIC 250MG; 25MG; 4MG; 1.8MG; OXIDE; CYANOCOBALAMIN; 30MG; 3000UNIT; 25MG DOCOSAHEXAENOIC ACID (DHA); FERROUS BISGLYCINATE; FOLIC ACID; IRON; IRON PROTEIN SUCCINYLATE; MAGNESIUM OXIDE; NIACINAMIDE; OMEGA-3 FATTY ACIDS; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; THIAMINE MONONITRATE; TOCOPHERYL ACET,DL- ALPHA; VITAMIN A; ZINC OXIDE BAL-CARE DHA ESSENTIAL ASCORBIC ACID; BETA 120MG; 2850UNIT; 219MG; MISC None Female 60 30 CAROTENE; CALCIUM 840UNIT; 2MG; 12MCG; CARBONATE; 262MG; 1MG; 220MCG; CHOLECALCIFEROL; CUPRIC 27MG; 25MG; 20MG; 374MG; OXIDE; CYANOCOBALAMIN; 0; 50MG; 4MG; 0; 1.8MG; DOCOSAHEXAENOIC ACID 3MG; 25MG (DHA); FOLIC ACID; IODINE; IRON; MAGNESIUM OXIDE; NIACINAMIDE; OMEGA-3 FATTY ACIDS; POLYSACCHARIDE IRON COMPLEX; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; SODIUM FEREDETATE (FERRAZONE); THIAMINE MONONITRATE; TOCOPHERYL ACET,DL- ALPHA; ZINC OXIDE

Page 20 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message TRINATE ASCORBIC ACID; BETA 120MG; 3000UNIT; 200MG; TABS None Female 30 30 CAROTENE; CALCIUM 400UNIT; 2MG; 12MCG; CARBONATE; 28MG; 1MG; 25MG; 20MG; CHOLECALCIFEROL; CUPRIC 25MG; 4MG; 1.8MG; 22MG; OXIDE; CYANOCOBALAMIN; 25MG FERROUS FUMARATE; FOLIC ACID; MAGNESIUM OXIDE; NIACINAMIDE; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; THIAMINE MONONITRATE; TOCOPHERYL ACET,DL- ALPHA; ZINC OXIDE

PRENATAL PLUS IRON ASCORBIC ACID; BETA 120MG; 0; 200MG; 400UNIT; TABS None Female 30 30 CAROTENE; CALCIUM 2MG; 12MCG; 1MG; 29MG; CARBONATE; 20MG; 10MG; 3MG; 1.84MG; CHOLECALCIFEROL; CUPRIC 22UNIT; 4000UNIT; 25MG OXIDE; CYANOCOBALAMIN; FOLIC ACID; IRON CARBONYL; NIACINAMIDE; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; THIAMINE MONONITRATE; TOCOPHERYL ACET,DL- ALPHA; VITAMIN A ACETATE (RETINYL ACETATE); ZINC OXIDE O-CAL PRENATAL ASCORBIC ACID; BETA 70MG; 0; 200MG; 400UNIT; TABS None Female 30 30 CAROTENE; CALCIUM 2MG; 12MCG; 15MG; 1MG; CARBONATE; 100MG; 17MG; 150MCG; CHOLECALCIFEROL; CUPRIC 12MG; 1.6MG; 1.5MG; SULFATE ANHYDROUS; 2500UNIT; 30UNIT; 15MG CYANOCOBALAMIN; FERROUS FUMARATE; FOLIC ACID; MAGNESIUM OXIDE; NIACINAMIDE; POTASSIUM IODIDE; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; THIAMINE MONONITRATE; VITAMIN A; VITAMIN E ACETATE (D- ALPHA); ZINC OXIDE

Page 21 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message PRENATAL MULTIVITAMIN + ASCORBIC ACID; BETA 120MG; 0; 200MG; 400UNIT; MISC None Female 60 30 DHA CAROTENE; CALCIUM 8MCG; 200MG; 28MG; CARBONATE; 800MCG; 20MG; 2.6MG; CHOLECALCIFEROL; 1.7MG; 1.8MG; 30UNIT; CYANOCOBALAMIN; 4000UNIT; 25MG DOCOSAHEXAENOIC ACID (DHA) (MICROALGAE); FERROUS FUMARATE; FOLIC ACID; NIACINAMIDE; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; THIAMINE MONONITRATE; TOCOPHERYL ACET,DL- ALPHA; VITAMIN A; ZINC OXIDE STUART PRENATAL + DHA ASCORBIC ACID; BETA 120MG; 0; 200MG; 400UNIT; MISC None Female 60 30 CAROTENE; CALCIUM 8MCG; 262MG; 98MG; 28MG; CARBONATE; 800MCG; 20MG; 656MG; CHOLECALCIFEROL; 2.6MG; 1.7MG; 1.8MG; CYANOCOBALAMIN; 30UNIT; 4000UNIT; 25MG DOCOSAHEXAENOIC ACID (DHA); EICOSAPENTAENOIC ACID (EPA); FERROUS FUMARATE; FOLIC ACID; NIACINAMIDE; OMEGA-3 FATTY ACIDS; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; THIAMINE MONONITRATE; TOCOPHERYL ACET,DL- ALPHA; VITAMIN A; ZINC OXIDE

Page 22 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message PRENATAL MULTI +DHA ASCORBIC ACID; BETA 100MG; 0; 150MG; 400UNIT; CAPS None Female 60 30 CAROTENE; CALCIUM 4MCG; 200MG; 28MG; 27MG; CARBONATE; 800MCG; 18MG; 228MG; CHOLECALCIFEROL; 2.6MG; 1.7MG; 1.5MG; CYANOCOBALAMIN; 11UNIT; 4000UNIT; 25MG DOCOSAHEXAENOIC ACID (DHA); EICOSAPENTAENOIC ACID (EPA); FERROUS FUMARATE; FOLIC ACID; NIACINAMIDE; OMEGA-3 FATTY ACIDS; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; THIAMINE MONONITRATE; TOCOPHERYL ACET,DL- ALPHA; VITAMIN A; ZINC OXIDE VENATAL-FA ASCORBIC ACID; BETA 120MG; 4000UNIT; 200MG; TABS None Female 30 30 CAROTENE; CALCIUM 400UNIT; 8MCG; 29MG; 1MG; CARBONATE; 20MG; 150MCG; 3MG; 3MG; CHOLECALCIFEROL; 3MG; 30UNIT; 15MG CYANOCOBALAMIN; FERROUS FUMARATE; FOLIC ACID; NIACINAMIDE; POTASSIUM IODIDE; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; THIAMINE MONONITRATE; TOCOPHERYL ACET,DL- ALPHA; ZINC OXIDE PRENATAL VITAMINS ASCORBIC ACID; BETA 120MG; 4000UNIT; 200MG; TABS None Female 30 30 CAROTENE; CALCIUM 400UNIT; 8MCG; 28MG; CARBONATE; 800MCG; 20MG; 2.6MG; CHOLECALCIFEROL; 1.7MG; 1.8MG; 30UNIT; 25MG CYANOCOBALAMIN; FERROUS FUMARATE; FOLIC ACID; NIACINAMIDE; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; THIAMINE MONONITRATE; TOCOPHERYL ACET,DL- ALPHA; ZINC OXIDE

Page 23 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message PRENATAL ASCORBIC ACID; BETA 120MG; 4000UNIT; 200MG; TABS None Female 30 30 CAROTENE; CALCIUM 400UNIT; 8MCG; 28MG; CARBONATE; 800MCG; 20MG; 2.6MG; CHOLECALCIFEROL; 1.7MG; 1.8MG; 30UNIT; 25MG CYANOCOBALAMIN; FERROUS FUMARATE; FOLIC ACID; NIACINAMIDE; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; THIAMINE MONONITRATE; TOCOPHERYL ACET,DL- ALPHA; ZINC OXIDE

MYNATAL ULTRACAPLET ASCORBIC ACID; BETA 120MG; 0; 200MG; 400UNIT; TABS None Female 30 30 CAROTENE; CALCIUM 2MG; 12MCG; 50MG; 1MG; CITRATE; 90MG; 20MG; 150MCG; CHOLECALCIFEROL; CUPRIC 20MG; 3.4MG; 3MG; 30UNIT; OXIDE; CYANOCOBALAMIN; 2700UNIT; 25MG DOCUSATE SODIUM; FOLIC ACID; IRON; NIACINAMIDE; POTASSIUM IODIDE; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; THIAMINE MONONITRATE; TOCOPHERYL ACET,DL- ALPHA; VITAMIN A PALMITATE (); ZINC OXIDE INATAL ULTRA ASCORBIC ACID; BETA 120MG; 0; 200MG; 2MG; TABS None None 30 30 CAROTENE; CALCIUM 12MCG; 50MG; 1MG; 90MG; CITRATE; CUPRIC OXIDE; 20MG; 150MCG; 20MG; CYANOCOBALAMIN; 3.4MG; 3MG; 2700UNIT; DOCUSATE SODIUM; FOLIC 400UNIT; 30UNIT; 25MG ACID; IRON; NIACINAMIDE; POTASSIUM IODIDE; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; THIAMINE MONONITRATE; VITAMIN A ACETATE (RETINYL ACETATE); VITAMIN D; VITAMIN E ACETATE (D-

Page 24 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message PRENATAL LOW IRON ASCORBIC ACID; BETA 120MG; 0; 200MG; 400UNIT; TABS None Female 30 30 CAROTENE; CALCIUM 2MG; 12MCG; 27MG; 1MG; SULFATE; 20MG; 10MG; 3MG; 1.84MG; CHOLECALCIFEROL; CUPRIC 22UNIT; 4000UNIT; 25MG OXIDE; CYANOCOBALAMIN; FERROUS FUMARATE; FOLIC ACID; NIACINAMIDE; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; THIAMINE MONONITRATE; TOCOPHERYL ACET,DL- ALPHA; VITAMIN A ACETATE (RETINYL ACETATE); ZINC OXIDE

ELITE-OB ASCORBIC ACID; BETA 120MG; 2100UNIT; 315UNIT; TABS None None 30 30 CAROTENE; 1MG; 15MCG; 20UNIT; CHOLECALCIFEROL; COPPER 1.25MG; 50MG; 15MG; 10MG; GLUCONATE; 10MG; 3.4MG; 2MG; 10MG CYANOCOBALAMIN; D-ALPHA- TOCOPHERYL ACID SUCCINATE; FOLIC ACID; IRON CARBONYL; MAGNESIUM OXIDE; NIACINAMIDE; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; THIAMINE MONONITRATE; ZINC OXIDE

OBSTETRIX DHA ASCORBIC ACID; BETA 120MG; 2700UNIT; 400UNIT; MISC None None 60 30 CAROTENE; 12MCG; 250MG; 50MG; CHOLECALCIFEROL; 100MG; 1MG; 29MG; 30MG; CYANOCOBALAMIN; 20MG; 387MG; 40MG; 3.4MG; DOCOSAHEXAENOIC ACID 65MCG; 3MG; 18UNIT; 25MG (DHA); DOCUSATE SODIUM; EICOSAPENTAENOIC ACID (EPA); FOLIC ACID; IRON CARBONYL; MAGNESIUM OXIDE; NIACINAMIDE; OMEGA-3 FATTY ACIDS; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; SODIUM SELENATE; THIAMINE HYDROCHLORIDE; TOCOPHERYL ACET,DL- ALPHA; ZINC OXIDE

Page 25 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message OBSTETRIX EC ASCORBIC ACID; BETA 120MG; 2700UNIT; 400UNIT; TABS None None 60 30 CAROTENE; 12MCG; 50MG; 1MG; 29MG; CHOLECALCIFEROL; 30MG; 20MG; 40MG; 3.4MG; CYANOCOBALAMIN; 65MCG; 3MG; 18UNIT; 25MG DOCUSATE SODIUM; FOLIC ACID; IRON CARBONYL; MAGNESIUM SILICATE; NIACINAMIDE; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; SELENIUM; THIAMINE HYDROCHLORIDE; TOCOPHERYL ACET,DL- ALPHA; ZINC OXIDE

NATACHEW ASCORBIC ACID; BETA 120MG; 2700UNIT; 400UNIT; CHEW None None 30 30 CAROTENE; 12MCG; 0; 0; 1MG; 28MG; CHOLECALCIFEROL; 20MG; 10MG; 3MG; 0; 2MG; CYANOCOBALAMIN; FERROUS 20UNIT BISGLYCINATE CHELATE; FERROUS FUMARATE; FOLIC ACID; IRON; NIACINAMIDE; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; SODIUM ASCORBATE; THIAMINE MONONITRATE; VITAMIN E ACETATE (D-ALPHA) COMPLETENATE ASCORBIC ACID; BETA 120MG; 1000UNIT; 400UNIT; CHEW None None 30 30 CAROTENE; 12MCG; 29MG; 1MG; 20MG; CHOLECALCIFEROL; 10MG; 3MG; 2MG; 11UNIT CYANOCOBALAMIN; FERROUS FUMARATE; FOLIC ACID; NIACINAMIDE; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; THIAMINE MONONITRATE; TOCOPHERYL ACET,DL-ALPHA

Page 26 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message SELECT-OB ASCORBIC ACID; BETA 60MG; 0; 400UNIT; 5MCG; CHEW None None 30 30 CAROTENE; 1MG; 25MG; 15MG; 29MG; CHOLECALCIFEROL; 2.5MG; 1.8MG; 1.6MG; CYANOCOBALAMIN; FOLIC 30UNIT; 1700UNIT; 15MG ACID; MAGNESIUM OXIDE; NIACINAMIDE; POLYSACCHARIDE IRON COMPLEX; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; THIAMINE MONONITRATE; TOCOPHERYL ACET,DL- ALPHA; VITAMIN A; ZINC PRENATAL FORMULA A-FREE ASCORBICOXIDE ACID; 33.333MG; 0; 10MCG; 0; TABS None Female 30 30 BIOFLAVONOIDS (VITAMIN P 333.333MG; 5MG; 0.1MG; SUBSTANCES); BIOTIN; 2MCG; 133.333UNIT; 9MG; CALCIUM ASCORBATE 266.667MCG; 0; 33.333MG; ANHYDROUS; CALCIUM 0.1MG; 10MG; 1MG; 2MG; CARBONATE; CALCIUM 2MG; 10UNIT; 7.5MG PANTOTHENATE; COPPER GLUCONATE; CYANOCOBALAMIN; ERGOCALCIFEROL; FERROUS FUMARATE; FOLIC ACID; HESPERIDIN; MAGNESIUM OXIDE; MANGANESE GLUCONATE; NIACINAMIDE; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; THIAMINE HYDROCHLORIDE; TOCOPHERYL ACID SUCCINATE,DL-ALPHA; ZINC CITRATE NEXA PLUS ASCORBIC ACID; BIOTIN; C. 28MG; 250MCG; 660MG; CAPS None None 30 30 COHNII ALGAL OIL (CAS# 160MG; 800UNIT; 350MG; 1258273-84-5); CALCIUM; 55MG; 29MG; 1.25MG; 25MG; CHOLECALCIFEROL; 30UNIT DOCOSAHEXAENOIC ACID (DHA) (MICROALGAE); DOCUSATE CALCIUM; FERROUS FUMARATE; FOLIC ACID; PYRIDOXINE HYDROCHLORIDE; TOCOPHEROL, D-ALPHA

Page 27 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message VINATE M ASCORBIC ACID; BIOTIN; 120MG; 30MCG; 200MG; TABS None None 30 30 CALCIUM CARBONATE; 10MG; 400UNIT; 25MCG; CALCIUM PANTOTHENATE; 2MG; 12MCG; 27MG; 1MG; CHOLECALCIFEROL; 25MG; 5MG; 20MG; 150MCG; CHROMIC CHLORIDE; CUPRIC 10MG; 3.4MG; 25MCG; OXIDE; CYANOCOBALAMIN; 20MCG; 3MG; 30UNIT; FERROUS FUMARATE; FOLIC 5000UNIT; 25MG ACID; MAGNESIUM OXIDE; MANGANESE; NIACINAMIDE; POTASSIUM IODIDE; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; SODIUM MOLYBDATE; SODIUM SELENATE; THIAMINE; TOCOPHERYL ACET,DL- ALPHA; VITAMIN A ACETATE (RETINYL ACETATE); ZINC OXIDE VITAMEDMD PLUS RX/QUATRE ASCORBIC ACID; BIOTIN; 60MG; 300MCG; 150MG; MISC None None 60 30 FOLIC CALCIUM CARBONATE; 10MG; 600UNIT; 2MG; CALCIUM PANTOTHENATE; 12MCG; 300MG; 400MCG; CHOLECALCIFEROL; COPPER 30MG; 600MCG; 20MG; AMINO ACID CHELATE; 150MCG; 25MG; 3.4MG; 3MG; CYANOCOBALAMIN; 30UNIT; 15MG DOCOSAHEXAENOIC ACID (DHA) (MICROALGAE); FOLIC ACID; IRON AMINO ACID CHELATE; LEVOMEFOLATE GLUCOSAMINE (QUATREFOLIC); NIACINAMIDE; POTASSIUM IODIDE; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN 5 PHOSPHATE SODIUM; THIAMINE MONONITRATE; TOCOPHERYL ACET,DL- ALPHA; ZINC AMINO ACID CHELATE

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Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message COMPLETE PRENATAL ASCORBIC ACID; BIOTIN; 60MG; 300MCG; 150MG; MISC None Female 60 30 MULTIVITAMIN/PRENATAL DHA CALCIUM CARBONATE; 10MG; 2MG; 12MCG; 300MG; CALCIUM PANTOTHENATE; 600UNIT; 30MG; 975MCG; COPPER AMINO ACID 2MG; 50MCG; 20MG; 25MG; CHELATE; 3.4MG; 75MCG; 3MG; CYANOCOBALAMIN; 30UNIT; 15MG DOCOSAHEXAENOIC ACID (DHA) (MICROALGAE); ERGOCALCIFEROL; FERROUS BISGLYCINATE CHELATE; FOLIC ACID; MANGANESE AMINO ACID CHELATE; MOLYBDENUM AMINO ACID CHELATE; NIACINAMIDE; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN 5 PHOSPHATE SODIUM; SELENIUM AMINO ACID CHELATE; THIAMINE MONONITRATE; TOCOPHERYL ACID SUCCINATE,DL-ALPHA; ZINC PRENATE ESSENTIAL ASCORBIC ACID; BIOTIN; 90MG; 280MCG; 145MG; CAPS None Female 30 30 CALCIUM CARBONATE; 220UNIT; 13MCG; 300MG; CHOLECALCIFEROL; 40MG; 29MG; 0; 400MCG; CYANOCOBALAMIN; 600MCG; 50MG; 150MCG; DOCOSAHEXAENOIC ACID 26MG; 10UNIT (DHA); EICOSAPENTAENOIC ACID (EPA); FERROUS ASPARTO GLYCINATE; FISH OIL; FOLIC ACID; LEVOMEFOLATE GLUCOSAMINE (QUATREFOLIC); MAGNESIUM OXIDE; POTASSIUM IODIDE; PYRIDOXINE HYDROCHLORIDE; TOCOPHEROL, DL-ALPHA

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Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message PNV-OMEGA ASCORBIC ACID; BIOTIN; 85MG; 250MCG; 140MG; CAPS None None 30 30 CALCIUM CARBONATE; 200UNIT; 12MCG; 300MG; CHOLECALCIFEROL; 40MG; 28MG; 400MCG; CYANOCOBALAMIN; 600MCG; 45MG; 150MCG; DOCOSAHEXAENOIC ACID 25MG; 10UNIT (DHA); EICOSAPENTAENOIC ACID (EPA); FERROUS FUMARATE; FOLIC ACID; L- METHYLFOLATE; MAGNESIUM OXIDE; POTASSIUM IODIDE; PYRIDOXINE; VITAMIN E

PRENATE MINI ASCORBIC ACID; BIOTIN; 60MG; 280MCG; 100MG; CAPS None Female 30 30 CALCIUM CARBONATE; 220UNIT; 13MCG; 350MG; CHOLECALCIFEROL; 400MCG; 29MG; 600MCG; CYANOCOBALAMIN; 25MG; 150MCG; 26MG; DOCOSAHEXAENOIC ACID 10UNIT; 25MG (DHA); FOLIC ACID; IRON CARBONYL; LEVOMEFOLATE GLUCOSAMINE (QUATREFOLIC); MAGNESIUM OXIDE; POTASSIUM IODIDE; PYRIDOXINE HYDROCHLORIDE; TOCOPHEROL, DL-ALPHA; VACCINIUM ANGUSTIFOLIUM(LOWBUSHBL UEBERRY

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Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message MYNATAL ASCORBIC ACID; BIOTIN; 120MG; 30MCG; 300MG; CAPS None None 30 30 CALCIUM CARBONATE; 25MCG; 2MG; 12MCG; CHROMIUM; CUPRIC OXIDE; 400UNIT; 65MG; 1MG; 25MG; CYANOCOBALAMIN; 5MG; 25MCG; 20MG; 10MG; ERGOCALCIFEROL; FERROUS 150MCG; 10MG; 3.4MG; 3MG; SULFATE; FOLIC ACID; 30UNIT; 5000UNIT; 25MG MAGNESIUM OXIDE; MANGANESE SULFATE; MOLYBDENUM; NIACINAMIDE; PANTOTHENIC ACID; POTASSIUM IODIDE; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; THIAMINE HYDROCHLORIDE; TOCOPHERYL ACET,DL- ALPHA; VITAMIN A PALMITATE (RETINYL PALMITATE); ZINC SULFATE (HEPTAHYDRATE) PRENA1/QUATREFOLIC ASCORBIC ACID; BIOTIN; 60MG; 300MCG; 10MG; CAPS None Female 30 30 CALCIUM PANTOTHENATE; 400UNIT; 8MCG; 200MG; CHOLECALCIFEROL; 30MG; 400MCG; 600MCG; CYANOCOBALAMIN; 20MG; 25MG; 1.7MG; 1.5MG; DOCOSAHEXAENOIC ACID 21UNIT; 7.5MG (DHA) (MICROALGAE); FERROUS FUMARATE; FOLIC ACID; LEVOMEFOLATE GLUCOSAMINE (QUATREFOLIC); NIACINAMIDE; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; THIAMINE MONONITRATE; TOCOPHERYL ACET,DL- ALPHA; ZINC OXIDE

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Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message PRENATAL 1 ASCORBIC ACID; BIOTIN; 60MG; 300MCG; 10MG; CAPS None Female 30 30 CALCIUM PANTOTHENATE; 400UNIT; 8MCG; 0; 975MCG; CHOLECALCIFEROL; 30MG; 20MG; 25MG; 1.7MG; CYANOCOBALAMIN; FERROUS 1.5MG; 21UNIT; 7.5MG FUMARATE; FOLIC ACID; IRON; NIACINAMIDE; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; THIAMINE MONONITRATE; VITAMIN E ACETATE (D-ALPHA); ZINC OXIDE TARON-C DHA ASCORBIC ACID; BIOTIN; 25MG; 300MCG; 5MG; 2MG; CAPS None None 30 30 CALCIUM PANTOTHENATE; 12.5MCG; 156MG; 39MG; CUPRIC SULFATE 53.5MG; 310MG; 1MG; 5MG; ANHYDROUS; 1.8MG; 200MG; 38MG; 25MG; CYANOCOBALAMIN; 3MG; 2MG; 10MG DOCOSAHEXAENOIC ACID (DHA); EICOSAPENTAENOIC ACID (EPA); FERROUS FUMARATE; FISH OIL; FOLIC ACID; MAGNESIUM SULFATE ANHYDROUS; NIACIN; OMEGA-3 FATTY ACIDS; POLYSACCHARIDE IRON COMPLEX; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; THIAMINE MONONITRATE; ZINC SULFATE (ANHYDROUS)

FOLIVANE-OB ASCORBIC ACID; BIOTIN; 210MG; 300MCG; 7MG; CAPS None None 30 30 CALCIUM PANTOTHENATE; 800MCG; 10MCG; 130MG; CUPRIC SULFATE 1MG; 6.9MG; 1.3MG; 20MG; ANHYDROUS; 92.4MG; 25MG; 5MG; 5MG; CYANOCOBALAMIN; FERROUS 18.2MG FUMARATE; FOLIC ACID; MAGNESIUM SULFATE ANHYDROUS; MANGANESE SULFATE; NIACIN; POLYSACCHARIDE IRON COMPLEX; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; THIAMINE MONONITRATE; ZINC SULFATE (ANHYDROUS)

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Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message EZFE FORTE ASCORBIC ACID; BIOTIN; 45MG; 150MCG; 10MG; CAPS None None 30 30 CALCIUM PANTOTHENATE; 1000MCG; 1000MCG; 20MG; CYANOCOBALAMIN; FOLIC 155MG; 25MG; 1.7MG; 1.5MG ACID; NIACINAMIDE; POLYSACCHARIDE IRON COMPLEX; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; THIAMINE MONONITRATE ULTIMATECARE ONE NF ASCORBIC ACID; BIOTIN; 25MG; 300MCG; 100MG; 0; 0; CAPS None None 30 30 CALCIUM; CALCIUM 800UNIT; 350MG; 50MG; ASCORBATE ANHYDROUS; 100MG; 7MG; 1MG; 150MCG; CALCIUM THREONATE; 20MG; 50MG; 50MG; 10MG; CHOLECALCIFEROL; 500MG; 50MG; 1.5MG; DOCOSAHEXAENOIC ACID 15UNIT; 5MG (DHA); DOCUSATE SODIUM; EICOSAPENTAENOIC ACID (EPA); FERROUS ASPARTO GLYCINATE; FOLIC ACID; IODINE; IRON CARBONYL; LINOLENIC ACID; MAGNESIUM OXIDE; NIACINAMIDE; OMEGA-3 FATTY ACIDS; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; TOCOPHERYL ACET,DL-ALPHA; ZINC OXIDE

NATELLE-EZ ASCORBIC ACID; BIOTIN; 120MG; 30MCG; 100MG; TABS None Female 30 30 CALCIUM; 400UNIT; 55MG; 2MG; CHOLECALCIFEROL; CHOLINE 12MCG; 25MG; 800MCG; BITARTRATE; COPPER; 50MG; 20MG; 8MG; 30MG; CYANOCOBALAMIN; FERROUS 3.5MG; 50MCG; 3MG; FUMARATE; FOLIC ACID; 2700UNIT; 20UNIT; 15MG MAGNESIUM; NIACIN; PANTOTHENIC ACID; PYRIDOXINE; RIBOFLAVIN; SELENIUM; THIAMINE; VITAMIN A; VITAMIN E; ZINC

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Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message NATALVIT ASCORBIC ACID; BIOTIN; 120MG; 10MCG; 200MG; TABS None None 30 30 CALCIUM; CHOLINE; COPPER; 30MG; 2MG; 12MCG; CYANOCOBALAMIN; 400UNIT; 75MG; 1MG; 25MG; ERGOCALCIFEROL; FERROUS 50MG; 20MG; 5MG; 50MG; FUMARATE; FOLIC ACID; 15MG; 3.5MG; 2MG; INOSITOL; MAGNESIUM; 4000UNIT; 15UNIT; 25MG NIACINAMIDE; PANTOTHENIC ACID; PHOSPHORUS; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; THIAMINE HYDROCHLORIDE; VITAMIN A; VITAMIN E; ZINC

TRICARE PRENATAL DHA ONE ASCORBIC ACID; BIOTIN; 60MG; 300MCG; 800UNIT; CAPS None None 30 30 CHOLECALCIFEROL; CUPRIC 2MG; 100MCG; 215MG; SULFATE ANHYDROUS; 25MG; 45MG; 27MG; 500MG; CYANOCOBALAMIN; 1MG; 20MG; 25MG; 3.4MG; DOCOSAHEXAENOIC ACID 3MG; 30UNIT; 10MG (DHA); DOCUSATE SODIUM; EICOSAPENTAENOIC ACID (EPA); FERROUS FUMARATE; FISH OIL; FOLIC ACID; INOSITOL NIACINATE (INOS HEXANICOTINATE); PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; THIAMINE MONONITRATE; VITAMIN E ACETATE (D-ALPHA); ZINC SULFATE (MONOHYDRATE)

PREFERAOB ONE ASCORBIC ACID; BIOTIN; 25MG; 30MCG; 400UNIT; CAPS None None 30 30 CHOLECALCIFEROL; 12MCG; 200MG; 1MG; 6MG; CYANOCOBALAMIN; 17MG; 22MG; 175MCG; DOCOSAHEXAENOIC ACID 50MG; 10UNIT; 15MG (DHA) (MICROALGAE); FOLIC ACID; IRON HEME POLYPEPTIDE; NIACINAMIDE; POLYSACCHARIDE IRON COMPLEX; POTASSIUM IODIDE; PYRIDOXINE HYDROCHLORIDE; TOCOPHERYL ACET,DL- ALPHA; ZINC OXIDE

Page 34 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message DIALYVITE 800 ASCORBIC ACID; BIOTIN; 60MG; 0.3MG; 0.006MG; TABS None None 200 90 CYANOCOBALAMIN; FOLIC 0.8MG; 20MG; 10MG; 10MG; ACID; NIACIN; PANTOTHENIC 1.7MG; 1.5MG ACID; PYRIDOXINE; RIBOFLAVIN; THIAMINE

POLY-VITAMIN DROPS ASCORBIC ACID; BIOTIN; 35MG/ML; 50MCG/ML; SOLN None None 50 30 CYANOCOBALAMIN; 2MCG/ML; 8MG/ML; 3MG/ML; NIACINAMIDE; 0.4MG/ML; 0.6MG/ML; PANTOTHENIC ACID; 0.5MG/ML; 1500UNIT/ML; PYRIDOXINE 400UNIT/ML; 5UNIT/ML HYDROCHLORIDE; RIBOFLAVIN; THIAMINE HYDROCHLORIDE; VITAMIN A (SYNTHETIC); VITAMIN D; VINATE PN CARE ASCORBICVITAMIN E ACID; CALCIUM 50MG; 0; 250MG; 0; TABS None None 30 30 ASCORBATE ANHYDROUS; 240UNIT; 2MG; 12MCG; CALCIUM CARBONATE; 50MG; 30MG; 1MG; 25MG; CALCIUM THREONATE; 20MG; 50MG; 3.4MG; 35MG; CHOLECALCIFEROL; CUPRIC 3MG; 3.5UNIT; 15MG OXIDE; CYANOCOBALAMIN; DOCUSATE SODIUM; FERROUS ASPARTO GLYCINATE; FOLIC ACID; MAGNESIUM OXIDE; NIACINAMIDE; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; SUCCINIC ACID (BUTANEDIOIC ACID); THIAMINE MONONITRATE; TOCOPHERYL ACET,DL- ALPHA; ZINC OXIDE

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Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message OB COMPLETE 400 ASCORBIC ACID; CALCIUM 110MG; 0; 0; 1000UNIT; CAPS None None 30 30 ASCORBATE ANHYDROUS; 1MG; 0.02MG; 320MG; 0; CALCIUM THREONATE; 10MG; 400MG; 1MG; 40MG; CHOLECALCIFEROL; CUPRIC 0; 10MG; 40MG; 3.4MG; 2MG; SULFATE ANHYDROUS; 30UNIT; 25MG CYANOCOBALAMIN; DOCOSAHEXAENOIC ACID (DHA); EICOSAPENTAENOIC ACID (EPA); FERROUS ASPARTO GLYCINATE; FISH OIL; FOLIC ACID; IRON CARBONYL; ; NIACIN; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; THIAMINE MONONITRATE; VITAMIN E; ZINC OXIDE

OB COMPLETE/DHA ASCORBIC ACID; CALCIUM 125MG; 0; 0; 1000UNIT; CAPS None None 60 30 ASCORBATE ANHYDROUS; 1MG; 15MCG; 0; 0; 10MG; CALCIUM THREONATE; 1MG; 30MG; 200MG; 3.4MG; CHOLECALCIFEROL; CUPRIC 2MG; 30UNIT; 25MG SULFATE ANHYDROUS; CYANOCOBALAMIN; DOCOSAHEXAENOIC ACID (DHA); EICOSAPENTAENOIC ACID (EPA); FERROUS ASPARTO GLYCINATE; FOLIC ACID; IRON CARBONYL; OMEGA-3 FATTY ACIDS; RIBOFLAVIN; THIAMINE MONONITRATE; TOCOPHEROL, D-ALPHA; ZINC OXIDE

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Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message ELITE-OB 400 ASCORBIC ACID; CALCIUM 100MG; 0; 0; 800UNIT; 1MG; CAPS None None 30 30 ASCORBATE ANHYDROUS; 0.02MG; 320MG; 0; 5MG; CALCIUM THREONATE; 400MG; 1.2MG; 35MG; 0; 0; CHOLECALCIFEROL; CUPRIC 10MG; 25MG; 3.4MG; 2MG; SULFATE ANHYDROUS; 30UNIT; 25MG CYANOCOBALAMIN; DOCOSAHEXAENOIC ACID (DHA); EICOSAPENTAENOIC ACID (EPA); FERROUS BISGLYCINATE CHELATE; FISH OIL; FOLIC ACID; IRON CARBONYL; LINOLEIC ACID; LINOLENIC ACID; NIACINAMIDE; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; THIAMINE MONONITRATE; TOCOPHEROL, D-ALPHA; ZINC OXIDE

GESTICARE DHA ASCORBIC ACID; CALCIUM 120MG; 200MG; 410UNIT; MISC None None 60 30 CARBONATE; 55MG; 8MCG; 250MG; CHOLECALCIFEROL; CHOLINE 0.625MG; 27MG; 1MG; 20MG; BITARTRATE; 150MCG; 50MG; 3MG; 3MG; CYANOCOBALAMIN; 30UNIT; 15MG DOCOSAHEXAENOIC ACID (DHA); EICOSAPENTAENOIC ACID (EPA); FERROUS FUMARATE; FOLIC ACID; NIACINAMIDE; POTASSIUM IODIDE; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; THIAMINE MONONITRATE; TOCOPHERYL ACET,DL- ALPHA; ZINC OXIDE

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Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message COMPLETE-RF PRENATAL ASCORBIC ACID; CALCIUM 120MG; 200MG; 400UNIT; TABS None None 30 30 CARBONATE; 2MG; 12MCG; 50MG; 1MG; CHOLECALCIFEROL; CUPRIC 90MG; 30MG; 20MG; 20MG; OXIDE; CYANOCOBALAMIN; 3.4MG; 3MG; 30UNIT; 25MG DOCUSATE SODIUM; FOLIC ACID; IRON CARBONYL; MAGNESIUM OXIDE; NIACINAMIDE; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; THIAMINE MONONITRATE; TOCOPHERYL ACET,DL- ALPHA; ZINC OXIDE

MARNATAL-F ASCORBIC ACID; CALCIUM 100MG; 200MG; 400UNIT; CAPS None None 30 30 CARBONATE; 2MG; 12MCG; 1MG; 25MG; CHOLECALCIFEROL; CUPRIC 20MG; 60MG; 5MG; 3.4MG; OXIDE; CYANOCOBALAMIN; 3MG; 30UNIT FOLIC ACID; MAGNESIUM OXIDE; NIACINAMIDE; POLYSACCHARIDE IRON COMPLEX; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; THIAMINE HYDROCHLORIDE; TOCOPHERYL ACET,DL-ALPHA

VP-PNV-DHA ASCORBIC ACID; CALCIUM 80MG; 50MG; 400UNIT; 1MG; CAPS None None 30 30 CARBONATE; 12MCG; 200MG; 15.8MG; CHOLECALCIFEROL; CUPRIC 28MG; 1MG; 30MG; 20MG; SULFATE ANHYDROUS; 16MG; 2.2MG; 6MG; 30UNIT; CYANOCOBALAMIN; 2500UNIT; 20MG DOCOSAHEXAENOIC ACID (DHA); EICOSAPENTAENOIC ACID (EPA); FERROUS FUMARATE; FOLIC ACID; MAGNESIUM OXIDE; NIACIN; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; THIAMINE MONONITRATE; TOCOPHEROL, D-ALPHA; VITAMIN A PALMITATE (RETINYL PALMITATE); ZINC OXIDE

Page 38 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message O-CAL FA ASCORBIC ACID; CALCIUM 90MG; 200MG; 400UNIT; TABS None Female 30 30 CARBONATE; 2MG; 12MCG; 27MG; 1MG; CHOLECALCIFEROL; CUPRIC 100MG; 20MG; 150MCG; SULFATE ANHYDROUS; 4MG; 3MG; 0.5MG; 3MG; CYANOCOBALAMIN; FERROUS 2500UNIT; 30UNIT; 15MG FUMARATE; FOLIC ACID; MAGNESIUM OXIDE; NIACINAMIDE; POTASSIUM IODIDE; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; SODIUM FLUORIDE; THIAMINE HYDROCHLORIDE; VITAMIN A ACETATE (RETINYL ACETATE); VITAMIN E ACETATE (D-ALPHA); ZINC OXIDE

PRENATE DHA ASCORBIC ACID; CALCIUM 90MG; 145MG; 220UNIT; CAPS None Female 30 30 CARBONATE; 13MCG; 300MG; 28MG; CHOLECALCIFEROL; 400MCG; 600MCG; 50MG; CYANOCOBALAMIN; 26MG; 10UNIT DOCOSAHEXAENOIC ACID (DHA); FERROUS FUMARATE; FOLIC ACID; LEVOMEFOLATE GLUCOSAMINE (QUATREFOLIC); MAGNESIUM OXIDE; PYRIDOXINE HYDROCHLORIDE; TOCOPHEROL, DL-ALPHA

ZATEAN-PN DHA ASCORBIC ACID; CALCIUM 85MG; 140MG; 200UNIT; CAPS None None 30 30 CARBONATE; 12MCG; 300MG; 27MG; CHOLECALCIFEROL; 400MCG; 600MCG; 45MG; CYANOCOBALAMIN; 25MG; 10UNIT DOCOSAHEXAENOIC ACID (DHA); FERROUS FUMARATE; FOLIC ACID; L- METHYLFOLATE; MAGNESIUM OXIDE; PYRIDOXINE HYDROCHLORIDE; TOCOPHEROL, D-ALPHA

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Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message PRENATAL 19 ASCORBIC ACID; CALCIUM 100MG; 200MG; 400UNIT; TABS None Female 30 30 CARBONATE; 12MCG; 25MG; 29MG; 1MG; CHOLECALCIFEROL; 15MG; 7MG; 20MG; 3MG; CYANOCOBALAMIN; 3MG; 1000UNIT; 30UNIT; DOCUSATE SODIUM; 20MG FERROUS FUMARATE; FOLIC ACID; NIACINAMIDE; PANTOTHENIC ACID; PYRIDOXINE; RIBOFLAVIN; THIAMINE MONONITRATE; VITAMIN A; VITAMIN E; ZINC OXIDE VITASPIRE ASCORBIC ACID; CALCIUM 120MG; 200MG; 400UNIT; TABS None None 30 30 CARBONATE; 8MCG; 1MG; 29MG; 20MG; CHOLECALCIFEROL; 150MCG; 3MG; 3MG; 3MG; CYANOCOBALAMIN; FOLIC 30UNIT; 15MG ACID; IRON CARBONYL; NIACINAMIDE; POTASSIUM IODIDE; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; THIAMINE MONONITRATE; TOCOPHERYL ACET,DL- MYNATE 90 PLUS ASCORBICALPHA; ZINC ACID; OXIDE CALCIUM 120MG; 250MG; 2MG; TBCR None None 30 30 CARBONATE; CUPRIC OXIDE; 12MCG; 50MG; 400UNIT; CYANOCOBALAMIN; 90MG; 1MG; 20MG; 0.15MG; DOCUSATE SODIUM; 20MG; 3.4MG; 3MG; ERGOCALCIFEROL; FERROUS 4000UNIT; 30UNIT; 25MG FUMARATE; FOLIC ACID; NIACINAMIDE; POTASSIUM IODIDE; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; THIAMINE MONONITRATE; VITAMIN A ACETATE (RETINYL ACETATE); VITAMIN E ACETATE (D-ALPHA); ZINC OXIDE

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Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message MYNATAL-Z ASCORBIC ACID; CALCIUM 70MG; 200MG; 2.2MCG; TABS None None 30 30 CARBONATE; 65MG; 1MG; 100MG; 17MG; CYANOCOBALAMIN; FERROUS 175MCG; 2.2MG; 1.6MG; FUMARATE; FOLIC ACID; 65MCG; 1.5MG; 4000UNIT; MAGNESIUM OXIDE; 400UNIT; 10UNIT; 15MG NIACINAMIDE; POTASSIUM IODIDE; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; SELENIUM; THIAMINE MONONITRATE; VITAMIN A; VITAMIN D; VITAMIN E; ZINC OXIDE CITRANATAL 90 DHA ASCORBIC ACID; CALCIUM 120MG; 160MG; 400UNIT; MISC None None 60 30 CITRATE; 2MG; 300MG; 50MG; 0.75MG; CHOLECALCIFEROL; CUPRIC 1MG; 90MG; 20MG; 150MCG; OXIDE; DOCOSAHEXAENOIC 20MG; 3.4MG; 3MG; 30UNIT; ACID (DHA) (MICROALGAE); 25MG DOCUSATE SODIUM; EICOSAPENTAENOIC ACID (EPA); FOLIC ACID; IRON; NIACINAMIDE; POTASSIUM IODIDE; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; THIAMINE; TOCOPHERYL ACET,DL- ALPHA; ZINC OXIDE CITRANATAL DHA ASCORBIC ACID; CALCIUM 120MG; 125MG; 400UNIT; MISC None None 60 30 CITRATE; 2MG; 250MG; 50MG; CHOLECALCIFEROL; CUPRIC 0.625MG; 0; 1MG; 27MG; 0; OXIDE; DOCOSAHEXAENOIC 20MG; 150MCG; 20MG; ACID (DHA); DOCUSATE 3.4MG; 3MG; 30UNIT; 25MG SODIUM; EICOSAPENTAENOIC ACID (EPA); FERROUS GLUCONATE; FOLIC ACID; IRON; IRON CARBONYL; NIACINAMIDE; POTASSIUM IODIDE; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; THIAMINE; TOCOPHERYL ACET,DL- ALPHA; ZINC OXIDE

Page 41 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message NATALVIRT CA ASCORBIC ACID; CALCIUM 120MG; 125MG; 400UNIT; MISC None None 60 30 CITRATE; 2MG; 300MG; 50MG; 0; 0; CHOLECALCIFEROL; CUPRIC 1MG; 35MG; 0; 20MG; OXIDE; DOCOSAHEXAENOIC 150MCG; 25MG; 3.4MG; 3MG; ACID (DHA); DOCUSATE 30UNIT; 25MG SODIUM; FERROUS GLUCONATE; FISH OIL; FOLIC ACID; IRON; IRON CARBONYL; NIACINAMIDE; POTASSIUM IODIDE; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; THIAMINE; TOCOPHERYL ACET,DL- ALPHA; ZINC OXIDE TRI RX ASCORBIC ACID; CALCIUM 120MG; 125MG; 400UNIT; TABS None None 30 30 CITRATE; 2MG; 50MG; 0; 1MG; 27MG; CHOLECALCIFEROL; CUPRIC 0; 20MG; 150MCG; 20MG; OXIDE; DOCUSATE SODIUM; 3.4MG; 3MG; 30UNIT; 25MG FERROUS GLUCONATE; FOLIC ACID; IRON; IRON CARBONYL; NIACINAMIDE; POTASSIUM IODIDE; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; THIAMINE MONONITRATE; TOCOPHERYL ACET,DL- VINATE CALCIUM ASCORBICALPHA; ZINC ACID; OXIDE CALCIUM 120MG; 125MG; 400UNIT; TABS None None 30 30 CITRATE; 2MG; 50MG; 1MG; 27MG; CHOLECALCIFEROL; CUPRIC 20MG; 150MCG; 20MG; OXIDE; DOCUSATE SODIUM; 3.4MG; 3MG; 30UNIT; FOLIC ACID; IRON; 2700UNIT; 25MG NIACINAMIDE; POTASSIUM IODIDE; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; THIAMINE HYDROCHLORIDE; TOCOPHERYL ACET,DL- ALPHA; VITAMIN A PALMITATE (RETINYL PALMITATE); ZINC OXIDE TARON-BC ASCORBIC ACID; CALCIUM 120MG; 125MG; 400UNIT; MISC None None 90 30 CITRATE; 1MG; 20MG; 0 CHOLECALCIFEROL; FOLIC ACID; IRON CARBONYL; PYRIDOXINE HYDROCHLORIDE

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Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message TARON-PREX ASCORBIC ACID; CALCIUM 25MG; 160MG; 170UNIT; CAPS None None 30 30 PHOSPHATE TRIBASIC; 265MG; 55MG; 30MG; 1.2MG; CHOLECALCIFEROL; 25MG; 30UNIT DOCOSAHEXAENOIC ACID (DHA); DOCUSATE SODIUM; FERROUS FUMARATE; FOLIC ACID; PYRIDOXINE HYDROCHLORIDE; TOCOPHEROL, D-ALPHA FOLIVANE-PRX DHA NF ASCORBIC ACID; CALCIUM 25MG; 160MG; 170UNIT; CAPS None None 30 30 PHOSPHATE TRIBASIC; 265MG; 55MG; 30MG; CHOLECALCIFEROL; 1.24MG; 25MG; 30UNIT DOCOSAHEXAENOIC ACID (DHA); DOCUSATE SODIUM; FERROUS FUMARATE; FOLIC ACID; PYRIDOXINE HYDROCHLORIDE; TOCOPHEROL, D-ALPHA TRIVEEN-PRX RNF ASCORBIC ACID; CALCIUM 28MG; 160MG; 400UNIT; CAPS None None 30 30 PHOSPHATE TRIBASIC; 300MG; 55MG; 26MG; 1.2MG; CHOLECALCIFEROL; 25MG; 30UNIT DOCOSAHEXAENOIC ACID (DHA); DOCUSATE SODIUM; FERROUS FUMARATE; FOLIC ACID; PYRIDOXINE HYDROCHLORIDE; TOCOPHEROL, D-ALPHA PNV-DHA+DOCUSATE ASCORBIC ACID; CALCIUM 28MG; 160MG; 400UNIT; CAPS None None 30 30 PHOSPHATE TRIBASIC; 300MG; 55MG; 27MG; CHOLECALCIFEROL; 1.25MG; 25MG; 30UNIT DOCOSAHEXAENOIC ACID (DHA); DOCUSATE SODIUM; FERROUS FUMARATE; FOLIC ACID; PYRIDOXINE HYDROCHLORIDE; TOCOPHEROL, D-ALPHA VIRT-SELECT ASCORBIC ACID; CALCIUM 28MG; 160MG; 800UNIT; CAPS None None 30 30 PHOSPHATE TRIBASIC; 325MG; 55MG; 29MG; CHOLECALCIFEROL; 1.25MG; 25MG; 30UNIT DOCOSAHEXAENOIC ACID (DHA); DOCUSATE SODIUM; FERROUS FUMARATE; FOLIC ACID; PYRIDOXINE HYDROCHLORIDE; TOCOPHEROL, D-ALPHA

Page 43 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message NATELLE ONE ASCORBIC ACID; CALCIUM 30MG; 102MG; 250MG; CAPS None None 30 30 PHOSPHATE TRIBASIC; 0.625MG; 28MG; 1MG; 25MG; DOCOSAHEXAENOIC ACID 30UNIT (DHA) (MICROALGAE); EICOSAPENTAENOIC ACID (EPA); FERROUS FUMARATE; FOLIC ACID; PYRIDOXINE HYDROCHLORIDE; TOCOPHEROL, D-ALPHA TRIVEEN-ONE ASCORBIC ACID; CALCIUM 30MG; 100MG; 250MG; CAPS None None 30 30 PHOSPHATE TRIBASIC; 27MG; 1MG; 25MG; 30UNIT DOCOSAHEXAENOIC ACID (DHA); FERROUS FUMARATE; FOLIC ACID; PYRIDOXINE HYDROCHLORIDE; TOCOPHEROL, D-ALPHA PRENATAL ASCORBIC ACID; CALCIUM 100MG; 200MG; 400UNIT; TABS None Female 30 30 SULFATE; 4MCG; 0.8MG; 27MG; 18MG; CHOLECALCIFEROL; 2.6MG; 1.7MG; 1.84MG; CYANOCOBALAMIN; FOLIC 11UNIT; 4000UNIT; 25MG ACID; IRON; NIACINAMIDE; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; THIAMINE MONONITRATE; TOCOPHERYL ACET,DL- ALPHA; VITAMIN A; ZINC OXIDE FOLCAPS OMEGA 3 ASCORBIC ACID; CALCIUM; 25MG; 150MG; 0; 0; CAPS None None 30 30 CALCIUM ASCORBATE 170UNIT; 260MG; 40MG; ANHYDROUS; CALCIUM 7MG; 1MG; 20MG; 30MG; THREONATE; 30MG; 330MG; 25MG; 30UNIT CHOLECALCIFEROL; DOCOSAHEXAENOIC ACID (DHA); EICOSAPENTAENOIC ACID (EPA); FERROUS ASPARTO GLYCINATE; FOLIC ACID; IRON CARBONYL; LINOLEIC ACID; LINOLENIC ACID; OMEGA-3 FATTY ACIDS; PYRIDOXINE HYDROCHLORIDE; VITAMIN E ACETATE (D-ALPHA)

Page 44 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message OB COMPLETE ASCORBIC ACID; CALCIUM; 120MG; 20MG; 800UNIT; CHEW None None 30 30 CHOLECALCIFEROL; 15MCG; 100MG; 5MG; 1MG; CYANOCOBALAMIN; 15MG; 1.2MG; 10MG; 10MG; DOCOSAHEXAENOIC ACID 3MG; 0; 2MG; 30UNIT; 2MG (DHA); FERROUS ASPARTO GLYCINATE; FOLIC ACID; IRON CARBONYL; MAGNESIUM; NIACINAMIDE; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; SODIUM ASCORBATE; THIAMINE MONONITRATE; VITAMIN E ACETATE (D-ALPHA); ZINC

OB COMPLETE PREMIER ASCORBIC ACID; 120MG; 800UNIT; 1MG; TABS None None 30 30 CHOLECALCIFEROL; COPPER; 15MCG; 100MG; 15MG; CYANOCOBALAMIN; 20MG; 1MG; 30MG; 10MG; DICALCIUM MALATE; 10MG; 3.4MG; 2MG; DIMAGNESIUM MALATE; 2100UNIT; 20UNIT; 10MG FERROUS ASPARTO GLYCINATE; FOLIC ACID; IRON CARBONYL; NIACIN; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; THIAMINE MONONITRATE; VITAMIN A; VITAMIN E; ZINC POLYVITAMIN/IRON ASCORBIC ACID; 60MG; 400UNIT; 0.8MG; CHEW Max Age: 12Y None CHOLECALCIFEROL; CUPRIC 4.5MCG; 12MG; 0.3MG; OXIDE; CYANOCOBALAMIN; 13.5MG; 1.05MG; 1.2MG; 0; FERROUS FUMARATE; FOLIC 1.05MG; 15UNIT; 2500UNIT; ACID; NIACINAMIDE; 8MG PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; SODIUM ASCORBATE; THIAMINE MONONITRATE; TOCOPHERYL ACET,DL- ALPHA; VITAMIN A PALMITATE (RETINYL PALMITATE); ZINC OXIDE

Page 45 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message RELNATE DHA ASCORBIC ACID; 100MG; 400UNIT; 1MG; CAPS None None 30 30 CHOLECALCIFEROL; CUPRIC 15MCG; 28MG; 1MG; 30MG; SULFATE ANHYDROUS; 200MG; 20MG; 3MG; 3MG; CYANOCOBALAMIN; FERROUS 30UNIT; 20MG FUMARATE; FOLIC ACID; MAGNESIUM; OMEGA-3 FATTY ACIDS; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; THIAMINE MONONITRATE; TOCOPHEROL, D-ALPHA; ZINC OXIDE

ELITE OB WITH DHA ASCORBIC ACID; 120MG; 400UNIT; 1MG; CAPS None None 60 30 CHOLECALCIFEROL; CUPRIC 15MCG; 28MG; 1.25MG; SULFATE ANHYDROUS; 200MG; 10MG; 3.4MG; 2MG; CYANOCOBALAMIN; FERROUS 30UNIT; 25MG FUMARATE; FOLIC ACID; OMEGA-3 FATTY ACIDS; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; THIAMINE MONONITRATE; TOCOPHEROL, D-ALPHA; ZINC OXIDE MULTI-VITAMIN/FLUORIDE ASCORBIC ACID; 35MG/ML; 400UNIT/ML; SOLN Max Age: 12Y None CHOLECALCIFEROL; 2MCG/ML; 5UNIT/ML; CYANOCOBALAMIN; D-ALPHA- 8MG/ML; 0.4MG/ML; TOCOPHERYL ACID 0.6MG/ML; 0.25MG/ML; SUCCINATE; NIACINAMIDE; 0.5MG/ML; 1500UNIT/ML PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN 5 PHOSPHATE SODIUM; SODIUM FLUORIDE; THIAMINE HYDROCHLORIDE; VITAMIN A PALMITATE (RETINYL PALMITATE)

Page 46 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message MULTI-VITAMIN/FLUORIDE ASCORBIC ACID; 35MG/ML; 400UNIT/ML; SOLN Max Age: 12 Y None CHOLECALCIFEROL; 2MCG/ML; 5UNIT/ML; CYANOCOBALAMIN; D-ALPHA- 8MG/ML; 0.4MG/ML; TOCOPHERYL ACID 0.6MG/ML; 0.5MG/ML; SUCCINATE; NIACINAMIDE; 0.5MG/ML; 1500UNIT/ML PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; SODIUM FLUORIDE; THIAMINE HYDROCHLORIDE; VITAMIN A PALMITATE (RETINYL PALMITATE) NATAFORT ASCORBIC ACID; 120MG; 400UNIT; 12MCG; 0; TABS None None 30 30 CHOLECALCIFEROL; 1MG; 60MG; 0; 20MG; 10MG; CYANOCOBALAMIN; FERROUS 3MG; 2MG; 11UNIT FUMARATE; FOLIC ACID; IRON; IRON CARBONYL; NIACINAMIDE; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; THIAMINE; TOCOPHERYL ACET,DL-ALPHA

PRENATA ASCORBIC ACID; 120MG; 400UNIT; 12MCG; CHEW None Female 30 30 CHOLECALCIFEROL; 29MG; 1MG; 20MG; 10MG; CYANOCOBALAMIN; FERROUS 3MG; 0; 2MG; 11UNIT FUMARATE; FOLIC ACID; NIACINAMIDE; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; SODIUM ASCORBATE; THIAMINE MONONITRATE; TOCOPHERYL ACET,DL-ALPHA

MVC-FLUORIDE ASCORBIC ACID; 60MG; 400UNIT; 4.5MCG; CHEW Max Age: 12Y None CHOLECALCIFEROL; 0.3MG; 13.5MG; 1.05MG; CYANOCOBALAMIN; FOLIC 1.2MG; 1MG; 1.05MG; ACID; NIACIN; PYRIDOXINE; 2500UNIT; 15UNIT RIBOFLAVIN; SODIUM FLUORIDE; THIAMINE; VITAMIN A PALMITATE (RETINYL PALMITATE); VITAMIN E

Page 47 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message MULTIVITAMIN/FLUORIDE ASCORBIC ACID; 60MG; 400UNIT; 4.5MCG; CHEW Max Age: 12Y None CHOLECALCIFEROL; 0.3MG; 13.5MG; 1.05MG; CYANOCOBALAMIN; FOLIC 1.2MG; 0; 1MG; 1.05MG; ACID; NIACINAMIDE; 15UNIT; 2500UNIT PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; SODIUM ASCORBATE; SODIUM FLUORIDE; THIAMINE HYDROCHLORIDE; TOCOPHERYL ACET,DL- ALPHA; VITAMIN A ACETATE (RETINYL ACETATE) POLY VITAMIN ASCORBIC ACID; 60MG; 400UNIT; 4.5MCG; CHEW Max Age: 12Y None CHOLECALCIFEROL; 0.3MG; 13.5MG; 1.05MG; CYANOCOBALAMIN; FOLIC 1.2MG; 0; 1.05MG; 15UNIT; ACID; NIACINAMIDE; 2500UNIT PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; SODIUM ASCORBATE; THIAMINE MONONITRATE; TOCOPHERYL ACET,DL- ALPHA; VITAMIN A PALMITATE (RETINYL MULTI VITAMIN/FLUORIDE ASCORBICPALMITATE) ACID; 60MG; 400UNIT; 4.5MCG; CHEW Max Age: 12Y None CHOLECALCIFEROL; 0.3MG; 13.5MG; 1.05MG; CYANOCOBALAMIN; FOLIC 1.2MG; 1MG; 1.05MG; ACID; NIACINAMIDE; 15UNIT; 2500UNIT PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; SODIUM FLUORIDE; THIAMINE HYDROCHLORIDE; TOCOPHERYL ACET,DL- ALPHA; VITAMIN A ACETATE (RETINYL ACETATE) MULTI-VITAMIN/FLUORIDE ASCORBIC ACID; 60MG; 400UNIT; 4.5MCG; CHEW Max Age: 12Y None CHOLECALCIFEROL; 0.3MG; 13.5MG; 1.05MG; CYANOCOBALAMIN; FOLIC 1.2MG; 0.25MG; 1.05MG; ACID; NIACINAMIDE; 2500UNIT; 15UNIT PYRIDOXINE; RIBOFLAVIN; SODIUM FLUORIDE; THIAMINE; VITAMIN A ACETATE (RETINYL ACETATE); VITAMIN E ACETATE (D-ALPHA)

Page 48 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message POLYVITAMIN ASCORBIC ACID; 35MG/ML; 400UNIT/ML; SOLN Max Age: 12Y None CHOLECALCIFEROL; 2MCG/ML; 8MG/ML; CYANOCOBALAMIN; 0.4MG/ML; 0.6MG/ML; NIACINAMIDE; PYRIDOXINE 0.5MG/ML; 5UNIT/ML; HYDROCHLORIDE; 1500UNIT/ML RIBOFLAVIN 5-PHOSPHATE; THIAMINE HYDROCHLORIDE; TOCOPHERYL ACET,DL- ALPHA; VITAMIN A PALMITATE (RETINYL PALMITATE)

MULTI- ASCORBIC ACID; 35MG/ML; 400UNIT/ML; SOLN Max Age: 12Y None VITAMIN/FLUORIDE/IRON CHOLECALCIFEROL; D-ALPHA- 5UNIT/ML; 10MG/ML; TOCOPHERYL ACID 8MG/ML; 0.4MG/ML; SUCCINATE; FERROUS 0.6MG/ML; 0.25MG/ML; SULFATE; NIACINAMIDE; 0.5MG/ML; 1500UNIT/ML PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; SODIUM FLUORIDE; THIAMINE HYDROCHLORIDE; VITAMIN A PALMITATE (RETINYL POLYVITAMIN/IRON ASCORBICPALMITATE) ACID; 35MG/ML; 400UNIT/ML; SOLN Max Age: 12Y None CHOLECALCIFEROL; FERROUS 10MG/ML; 8MG/ML; SULFATE; NIACINAMIDE; 0.4MG/ML; 0.6MG/ML; PYRIDOXINE 0.5MG/ML; 5UNIT/ML; HYDROCHLORIDE; 1500UNIT/ML RIBOFLAVIN 5-PHOSPHATE; THIAMINE HYDROCHLORIDE; TOCOPHERYL ACET,DL- ALPHA; VITAMIN A PALMITATE (RETINYL PALMITATE)

TRI-VIT/FLUORIDE ASCORBIC ACID; 35MG/ML; 400UNIT/ML; SOLN Max Age: 12Y None CHOLECALCIFEROL; SODIUM 0.25MG/ML; 1500UNIT/ML FLUORIDE; VITAMIN A PALMITATE (RETINYL PALMITATE) TRI-VITAMIN ASCORBIC ACID; 35MG/ML; 400UNIT/ML; SOLN Max Age: 12Y None CHOLECALCIFEROL; VITAMIN 1500UNIT/ML A PALMITATE (RETINYL PALMITATE)

Page 49 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message POLY-VITAMIN/IRON DROPS ASCORBIC ACID; 60MG/ML; 4.5MCG/ML; SOLN Max Age: 12Y None CYANOCOBALAMIN; IRON; 10MG/ML; 13.5MG/ML; NIACINAMIDE; PYRIDOXINE 1.05MG/ML; 1.2MG/ML; HYDROCHLORIDE; 1.05MG/ML; 2500UNIT/ML; RIBOFLAVIN; THIAMINE 400UNIT/ML; 11UNIT/ML HYDROCHLORIDE; VITAMIN A (SYNTHETIC); VITAMIN D; VITAMIN E POLY-VI-SOL ASCORBIC ACID; 35MG/ML; 2MCG/ML; SOLN Max Age: 12Y None CYANOCOBALAMIN; 8MG/ML; 0.4MG/ML; NIACINAMIDE; PYRIDOXINE 0.6MG/ML; 0.5MG/ML; HYDROCHLORIDE; 1500UNIT/ML; 400UNIT/ML; RIBOFLAVIN; THIAMINE 5UNIT/ML HYDROCHLORIDE; VITAMIN A (SYNTHETIC); VITAMIN D; VITAMIN E TRI-VIT/FLUORIDE/IRON ASCORBIC ACID; FLUORIDE; 35MG/ML; 0.25MG/ML; SOLN Max Age: 12Y None IRON; VITAMIN A; VITAMIN D 10MG/ML; 1500UNIT/ML; 400UNIT/ML POLY-VI-SOL/IRON ASCORBIC ACID; IRON; 35MG/ML; 10MG/ML; SOLN Max Age: 12Y None NIACIN; PYRIDOXINE 8MG/ML; 0.4MG/ML; HYDROCHLORIDE; 0.6MG/ML; 0.5MG/ML; RIBOFLAVIN; THIAMINE 1500UNIT/ML; 400UNIT/ML; HYDROCHLORIDE; VITAMIN 5UNIT/ML A; VITAMIN D; VITAMIN E

TRI-VI-SOL/IRON ASCORBIC ACID; IRON; 35MG/ML; 10MG/ML; SOLN Max Age: 12Y None VITAMIN A (SYNTHETIC); 1500UNIT/ML; 400UNIT/ML VITAMIN D TRI-VITAMIN/FLUORIDE ASCORBIC ACID; SODIUM 35MG/ML; 0.5MG/ML; SOLN Max Age: 12Y None FLUORIDE; VITAMIN A; 1500UNIT/ML; 400UNIT/ML VITAMIN D ASPIRIN ASPIRIN 81MG CHEW Min Age: 12Y None OXYCODONE/ASPIRIN ASPIRIN; OXYCODONE 325MG; 4.835MG TABS None None 120 30 HYDROCHLORIDE ATENOLOL ATENOLOL 100MG TABS Min Age: 21Y None AGE 0-21 BILL CCS ATENOLOL ATENOLOL 50MG TABS Min Age: 21Y None AGE 0-21 BILL CCS ATENOLOL ATENOLOL 25MG TABS Min Age: 21Y None AGE 0-21 BILL CCS ATORVASTATIN CALCIUM ATORVASTATIN CALCIUM 10MG TABS Min Age: 21Y None 30 30 AGE 0-21 BILL CCS ATORVASTATIN CALCIUM ATORVASTATIN CALCIUM 20MG TABS Min Age: 21Y None 30 30 AGE 0-21 BILL CCS ATORVASTATIN CALCIUM ATORVASTATIN CALCIUM 40MG TABS Min Age: 21Y None 30 30 AGE 0-21 BILL CCS ATORVASTATIN CALCIUM ATORVASTATIN CALCIUM 80MG TABS Min Age: 21Y None 30 30 AGE 0-21 BILL CCS

Page 50 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message AUGMENTED BETAMETHASONE AUGMENTED 0.05% LOTN None None 60 30 DIPROPIONATE BETAMETHASONE DIPROPIONATE AUGMENTED BETAMETHASONE AUGMENTED 0.05% CREA None None 120 30 DIPROPIONATE BETAMETHASONE DIPROPIONATE AUGMENTED BETAMETHASONE AUGMENTED 0.05% OINT None None 60 30 DIPROPIONATE BETAMETHASONE DIPROPIONATE AUGMENTED BETAMETHASONE AUGMENTED 0.05% GEL None None 60 30 DIPROPIONATE BETAMETHASONE DIPROPIONATE AZATHIOPRINE AZATHIOPRINE 50MG TABS Min Age: 21Y None 120 30 AGE 0-21 BILL CCS AZASAN AZATHIOPRINE 75MG TABS Min Age: 21Y None Use azathioprine 50 mg; AGE 0- 21 BILL CCS

AZASAN AZATHIOPRINE 100MG TABS Min Age: 21Y None Use azathioprine 50 mg; AGE 0- 21 BILL CCS

AZELASTINE HCL AZELASTINE HYDROCHLORIDE 137MCG/SPRAY SOLN None None 30 30 Use nasal steroids & an oral antihistamine AZELASTINE HCL AZELASTINE HYDROCHLORIDE 0.05% SOLN None None 6 30 Use ketotifen

EDARBYCLOR AZILSARTAN MEDOXOMIL; 40MG; 12.5MG TABS Min Age: 21Y None AGE 0-21 BILL CHLORTHALIDONE CCS EDARBYCLOR AZILSARTAN MEDOXOMIL; 40MG; 25MG TABS Min Age: 21Y None AGE 0-21 BILL CHLORTHALIDONE CCS AZITHROMYCIN AZITHROMYCIN 1GM PACK None None 2 90 AZITHROMYCIN AZITHROMYCIN 250MG TABS None None 30 30 AZITHROMYCIN AZITHROMYCIN 600MG TABS None None 30 30 AZITHROMYCIN AZITHROMYCIN 500MG TABS None None 3 3 Member allowed 2 fills per 90 days

AZITHROMYCIN AZITHROMYCIN 200MG/5ML SUSR None None 2 90 BALSALAZIDE DISODIUM BALSALAZIDE DISODIUM 750MG CAPS None None 270 30 QVAR BECLOMETHASONE 40MCG/ACT AERS None None 17.4 30 DIPROPIONATE QVAR BECLOMETHASONE 80MCG/ACT AERS None None 17.4 30 DIPROPIONATE BENAZEPRIL HCL BENAZEPRIL HCL 5MG TABS Min Age: 21Y None AGE 0-21 BILL CCS BENAZEPRIL HCL BENAZEPRIL HCL 10MG TABS Min Age: 21Y None AGE 0-21 BILL CCS BENAZEPRIL HCL BENAZEPRIL HCL 20MG TABS Min Age: 21Y None AGE 0-21 BILL CCS

Page 51 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message BENAZEPRIL HCL BENAZEPRIL HCL 40MG TABS Min Age: 21Y None AGE 0-21 BILL CCS BENAZEPRIL BENAZEPRIL HCL; 5MG; 6.25MG TABS Min Age: 21Y None AGE 0-21 BILL HCL/HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE CCS. Use single ingredients - benazepril+HCTZ

BENAZEPRIL BENAZEPRIL HCL; 10MG; 12.5MG TABS Min Age: 21Y None AGE 0-21 BILL HCL/HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE CCS

BENAZEPRIL BENAZEPRIL HCL; 20MG; 12.5MG TABS Min Age: 21Y None AGE 0-21 BILL HCL/HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE CCS

BENAZEPRIL BENAZEPRIL HCL; 20MG; 25MG TABS Min Age: 21Y None AGE 0-21 BILL HCL/HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE CCS

BENZOYL PEROXIDE BENZOYL PEROXIDE 10% GEL None None 60 30 BENZOYL PEROXIDE BENZOYL PEROXIDE 2.5% GEL None None 60 30 FLINTSTONES COMPLETE BETA CAROTENE; BIOTIN; 0; 40MCG; 10MG; 100MG; CHEW Max Age: 12 Y None CALCIUM PANTOTHENATE; 400UNIT; 38MG; 2MG; 6MCG; CALCIUM PHOSPHATE; 18MG; 400MCG; 20MG; CHOLECALCIFEROL; CHOLINE 15MG; 100MG; 150MCG; BITARTRATE; CUPRIC OXIDE; 2MG; 1.7MG; 60MG; 1.5MG; CYANOCOBALAMIN; FERROUS 3000UNIT; 30UNIT; 12MG FUMARATE; FOLIC ACID; MAGNESIUM; NIACINAMIDE; PHOSPHORUS; POTASSIUM IODIDE; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; SODIUM ASCORBATE; THIAMINE MONONITRATE; VITAMIN A ACETATE (RETINYL ACETATE); VITAMIN E ACETATE (D-ALPHA); ZINC OXIDE

BETAMETHASONE BETAMETHASONE 0.05% OINT None None 120 30 DIPROPIONATE DIPROPIONATE BETAMETHASONE BETAMETHASONE 0.05% LOTN None None 120 30 DIPROPIONATE DIPROPIONATE CLOTRIMAZOLE/BETAMETHASO BETAMETHASONE 0.05%; 1% CREA None None 180 30 NE DIPROPIONATE DIPROPIONATE; CLOTRIMAZOLE BETAMETHASONE VALERATE BETAMETHASONE VALERATE 0.1% CREA None None 240 30

BETAMETHASONE VALERATE BETAMETHASONE VALERATE 0.1% LOTN None None 240 30

Page 52 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message KPN PRENATAL BIOFLAVONOIDS (VITAMIN P 21.67MG; 333.33MG; TABS None None 30 30 SUBSTANCES); CALCIUM; 33.33MG; 3.33MG; CALCIUM ASCORBATE 133.33UNIT; 0.03MG; 2MCG; ANHYDROUS; CALCIUM 33.33MG; 0.13MG; 33.33MG; PANTOTHENATE; 0.03MG; 10MG; 2MG; CHOLECALCIFEROL; COPPER 0.01MG; 0.83MG; 2MG; 2MG; GLUCONATE; 2666.67UNIT; 10UNIT; CYANOCOBALAMIN; FERROUS 0.03MG FUMARATE; FOLIC ACID; MAGNESIUM OXIDE; MANGANESE GLUCONATE; NIACIN; POTASSIUM GLUCONATE; POTASSIUM IODIDE; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; THIAMINE HYDROCHLORIDE; VITAMIN A; VITAMIN E; ZINC GLUCONATE PRENATE BIOTIN; BLUEBERRY FRUIT 280MCG; 25MG; 250MCG; CHEW None Female 30 30 EXTRACT; BORON AMINO 500MG; 300UNIT; 125MCG; ACID CHELATE; CALCIUM 400MCG; 600MCG; 50MG; CARBONATE; 10MG CHOLECALCIFEROL; CYANOCOBALAMIN; FOLIC ACID; LEVOMEFOLATE GLUCOSAMINE (QUATREFOLIC); MAGNESIUM OXIDE; PYRIDOXINE HYDROCHLORIDE

Page 53 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message OB COMPLETE ONE BIOTIN; CALCIUM 200MCG; 70MG; 25MG; 5MG; CAPS None None 30 30 ASCORBATE ANHYDROUS; 1200UNIT; 1MG; 50MCG; CALCIUM CARBONATE; 25MG; 300MG; 40MG; 10MG; CALCIUM THREONATE; 476MG; 700MCG; 40MG; CHOLECALCIFEROL; CUPRIC 300MCG; 25MG; 10MG; SULFATE ANHYDROUS; 150MCG; 30MG; 4MG; 2MG; CYANOCOBALAMIN; 30UNIT; 15MG DICALCIUM MALATE; DOCOSAHEXAENOIC ACID (DHA); EICOSAPENTAENOIC ACID (EPA); FERROUS ASPARTO GLYCINATE; FISH OIL; FOLIC ACID; IRON CARBONYL; LEVOMEFOLATE GLUCOSAMINE (QUATREFOLIC); MAGNESIUM OXIDE; NIACINAMIDE; POTASSIUM IODIDE; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; THIAMINE MONONITRATE; TOCOPHERYL ACET,DL- ALPHA; ZINC OXIDE

HEMENATAL OB + DHA BIOTIN; CALCIUM 30MCG; 10MG; 400UNIT; MISC None None 60 30 PANTOTHENATE; 0.8MG; 12MCG; 10UNIT; CHOLECALCIFEROL; CUPRIC 200MG; 2.5MG; 1MG; 6MG; SULFATE ANHYDROUS; 0.5MG; 17MG; 203MG; 28MG; CYANOCOBALAMIN; D-ALPHA- 250MCG; 50MG; 1.6MG; TOCOPHERYL ACID 65MCG; 1.5MG; 4.5MG SUCCINATE; DOCOSAHEXAENOIC ACID (DHA); DOCOSAPENTAENOIC ACID (DPA); FOLIC ACID; IRON HEME POLYPEPTIDE; LINOLEIC ACID; NIACINAMIDE; OMEGA-3 FATTY ACIDS; POLYSACCHARIDE IRON COMPLEX; POTASSIUM IODIDE; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; SODIUM SELENATE; THIAMINE MONONITRATE; ZINC OXIDE

Page 54 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message HEMENATAL OB BIOTIN; CALCIUM 30MCG; 10MG; 400UNIT; TABS None Female 30 30 PANTOTHENATE; 0.8MG; 12MCG; 10UNIT; CHOLECALCIFEROL; CUPRIC 1MG; 6MG; 17MG; 28MG; SULFATE ANHYDROUS; 250MCG; 50MG; 1.6MG; CYANOCOBALAMIN; D-ALPHA- 65MCG; 1.5MG; 4.5MG TOCOPHERYL ACID SUCCINATE; FOLIC ACID; IRON HEME POLYPEPTIDE; NIACINAMIDE; POLYSACCHARIDE IRON COMPLEX; POTASSIUM IODIDE; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; SODIUM SELENATE; THIAMINE MONONITRATE; ZINC OXIDE

VP-ERA OB PLUS BIOTIN; CALCIUM 30MCG; 10MG; 400UNIT; TABS None None 30 30 PANTOTHENATE; 0.8MG; 12MCG; 10UNIT; CHOLECALCIFEROL; CUPRIC 1MG; 6MG; 17MG; 22MG; SULFATE ANHYDROUS; 175MCG; 50MG; 1.6MG; CYANOCOBALAMIN; D-ALPHA- 65MCG; 1.5MG; 15MG TOCOPHERYL ACID SUCCINATE; FOLIC ACID; IRON HEME POLYPEPTIDE; NIACINAMIDE; POLYSACCHARIDE IRON COMPLEX; POTASSIUM IODIDE; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; SODIUM SELENATE; THIAMINE MONONITRATE; ZINC OXIDE

Page 55 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message PRENATAL BIOTIN; CALCIUM; CALCIUM 25MCG; 50MG; 25MG; 2.5MG; TABS None Female 30 30 ASCORBATE ANHYDROUS; 0.5MG; 2.5MCG; 100UNIT; CALCIUM PANTOTHENATE; 6.75MG; 200MCG; 15MG; COPPER GLUCONATE; 0.5MG; 5MG; 0.75MG; CYANOCOBALAMIN; 0.75MG; 0.5MG; 3.75UNIT; ERGOCALCIFEROL; FERROUS 500UNIT; 3.75MG FUMARATE; FOLIC ACID; MAGNESIUM OXIDE; MANGANESE GLUCONATE; NIACINAMIDE; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; THIAMINE HYDROCHLORIDE; TOCOPHERYL ACID SUCCINATE,DL-ALPHA; VITAMIN A PALMITATE (RETINYL PALMITATE); ZINC CITRATE

BUDESONIDE BUDESONIDE 0.25MG/2ML SUSP Max Age: 8Y None 120 30

BUDESONIDE BUDESONIDE 0.5MG/2ML SUSP Max Age: 8Y None 240 30

PULMICORT BUDESONIDE 1MG/2ML SUSP None None 120 30 PULMICORT FLEXHALER BUDESONIDE 90MCG/ACT AEPB Min Age: 6Y None 1 30 PULMICORT FLEXHALER BUDESONIDE 180MCG/ACT AEPB Min Age: 6Y None 1 30

SYMBICORT BUDESONIDE; FORMOTEROL 80MCG/ACT; 4.5MCG/ACT AERO None None 10.2 30 FUMARATE DIHYDRATE

SYMBICORT BUDESONIDE; FORMOTEROL 160MCG/ACT; 4.5MCG/ACT AERO None None 10.2 30 FUMARATE DIHYDRATE

BUDEPRION SR BUPROPION HCL 150MG TB12 None None 90 30 BUPROPION HCL ER BUPROPION HCL 100MG TB12 None None 90 30 BUPROPION HCL SR BUPROPION HCL 200MG TB12 None None 60 30 BUPROPION HCL XL BUPROPION HCL 150MG TB24 None None 60 30 BUPROPION HCL XL BUPROPION HCL 300MG TB24 None None 30 30 BUSPIRONE HCL BUSPIRONE HYDROCHLORIDE 7.5MG TABS None None 90 30

BUSPIRONE HCL BUSPIRONE HYDROCHLORIDE 5MG TABS None None 90 30

BUSPIRONE HCL BUSPIRONE HYDROCHLORIDE 10MG TABS None None 90 30

BUSPIRONE HCL BUSPIRONE HYDROCHLORIDE 15MG TABS None None 90 3

BUSPIRONE HCL BUSPIRONE HYDROCHLORIDE 30MG TABS None None 60 30

Page 56 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message CALCIPOTRIENE CALCIPOTRIENE 0.005% OINT None None 60 30 Use 2 medium to high potency steroid CALCIPOTRIENE CALCIPOTRIENE 0.005% CREA None None 60 30 Use 2 medium to high potency steroid CALCITRIOL CALCITRIOL 3MCG/GM OINT None None 100 30 Use 2 medium to high potency steroid CALCITRIOL CALCITRIOL 0.25MCG CAPS None None 30 30 CALCITRIOL CALCITRIOL 0.5MCG CAPS None None 60 30 CALCIUM ACETATE CALCIUM ACETATE 667MG CAPS Min Age: 21Y None AGE 0-21 BILL CCS PHOSLYRA CALCIUM ACETATE 667MG/5ML SOLN Min Age: 21Y None AGE 0-21 BILL CCS CALCIUM ACETATE CALCIUM ACETATE 667MG TABS Min Age: 21Y None AGE 0-21 BILL CCS OB COMPLETE PETITE CALCIUM ASCORBATE 125MG; 1000UNIT; 1MG; CAPS None Female 30 30 ANHYDROUS; 15MCG; 0; 5MG; 1MG; 35MG; CHOLECALCIFEROL; CUPRIC 200MG; 30MG; 3.4MG; 2MG; SULFATE ANHYDROUS; 30UNIT; 25MG CYANOCOBALAMIN; DOCOSAHEXAENOIC ACID (DHA); FERROUS ASPARTO GLYCINATE; FOLIC ACID; IRON CARBONYL; OMEGA-3 FATTY ACIDS; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; THIAMINE MONONITRATE; VITAMIN E ACETATE (D-ALPHA); ZINC OXIDE

Page 57 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message NESTABS DHA CALCIUM CARBONATE; 45MG; 155MG; 450UNIT; MISC None Female 60 30 CALCIUM FORMATE; 55MG; 10MCG; 230MG; CHOLECALCIFEROL; CHOLINE 30MG; 32MG; 1000MCG; BITARTRATE; 100MCG; 50MG; 3MG; CYANOCOBALAMIN; 120MG; 3MG; 30UNIT; 10MG DOCOSAHEXAENOIC ACID (DHA); EICOSAPENTAENOIC ACID (EPA); FERROUS BISGLYCINATE CHELATE; FOLIC ACID; POTASSIUM IODIDE; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; SODIUM ASCORBATE; THIAMINE MONONITRATE; TOCOPHERYL ACET,DL- ALPHA; ZINC OXIDE NESTABS CALCIUM CARBONATE; 65MG; 155MG; 450UNIT; TABS None Female 30 30 CALCIUM FORMATE; 55MG; 10MCG; 32MG; CHOLECALCIFEROL; CHOLINE 1000MCG; 100MCG; 50MG; BITARTRATE; 3MG; 120MG; 3MG; 30UNIT; CYANOCOBALAMIN; FERROUS 10MG BISGLYCINATE CHELATE; FOLIC ACID; POTASSIUM IODIDE; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; SODIUM ASCORBATE; THIAMINE MONONITRATE; TOCOPHERYL ACET,DL- ALPHA; ZINC OXIDE FOLBECAL CALCIUM CARBONATE; 200MG; 12MCG; 1MG; 75MG TABS None Female 30 30 CYANOCOBALAMIN; FOLIC ACID; PYRIDOXINE HYDROCHLORIDE MACNATAL CN DHA CALCIUM CITRATE; 100MG; 400UNIT; 250MG; CAPS None Female 30 30 CHOLECALCIFEROL; 50MG; 0; 1MG; 28MG; 25MG; DOCOSAHEXAENOIC ACID 30UNIT (DHA); DOCUSATE SODIUM; EICOSAPENTAENOIC ACID (EPA); FOLIC ACID; IRON CARBONYL; PYRIDOXINE HYDROCHLORIDE; TOCOPHERYL ACET,DL-ALPHA

Page 58 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message PRENAISSANCE BALANCE CALCIUM CITRATE; 104MG; 400UNIT; 260MG; CAPS None Female 30 30 CHOLECALCIFEROL; 50MG; 1MG; 30MG; 25MG; DOCOSAHEXAENOIC ACID 30UNIT (DHA); DOCUSATE SODIUM; FOLIC ACID; IRON CARBONYL; PYRIDOXINE HYDROCHLORIDE; TOCOPHERYL ACET,DL-ALPHA

VINATE IC CALCIUM PANTOTHENATE; 10MG; 0.8MG; 15MCG; CAPS None Female 30 30 CUPRIC SULFATE 162MG; 1MG; 6.9MG; 1.3MG; ANHYDROUS; 30MG; 115.2MG; 5MG; 6MG; CYANOCOBALAMIN; FERROUS 200MG; 10MG; 18.2MG FUMARATE; FOLIC ACID; MAGNESIUM SULFATE ANHYDROUS; MANGANESE SULFATE; NIACINAMIDE; POLYSACCHARIDE IRON COMPLEX; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; SODIUM ASCORBATE; THIAMINE MONONITRATE; ZINC SULFATE (ANHYDROUS) PUREFE OB PLUS CALCIUM PANTOTHENATE; 10MG; 0.8MG; 15MCG; CAPS None Female 30 30 CUPRIC SULFATE 162MG; 1MG; 6.9MG; 1.3MG; ANHYDROUS; 30MG; 115.2MG; 5MG; 6MG; CYANOCOBALAMIN; FERROUS 200MG; 10MG; 18.2MG FUMARATE; FOLIC ACID; MAGNESIUM SULFATE ANHYDROUS; MANGANESE SULFATE; NIACINAMIDE; POLYSACCHARIDE IRON COMPLEX; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; SODIUM ASCORBATE; THIAMINE MONONITRATE; ZINC SULFATE (ANHYDROUS)

Page 59 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message PRENATAL-U CALCIUM PANTOTHENATE; 10MG; 0.8MG; 15MCG; CAPS None Female 30 30 CUPRIC SULFATE 106.5MG; 1MG; 1.3MG; ANHYDROUS; 30MG; 5MG; 6MG; 200MG; CYANOCOBALAMIN; FERROUS 10MG FUMARATE; FOLIC ACID; MANGANESE SULFATE; NIACINAMIDE; PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN; SODIUM ASCORBATE; THIAMINE MONONITRATE CALVITE P&D CALCIUM PHOSPHATE 105MG; 120UNIT; 81MG TABS None None 60 30 DIBASIC; CHOLECALCIFEROL; PHOSPHORUS

ZINGIBER CALCIUM; CALCIUM 124.1MG; 0; 0; 1200MCG; TABS None Female 60 30 PHOSPHATE DIBASIC; 40MG; 100MG CALCIUM PHOSPHATE TRIBASIC; FOLIC ACID; PYRIDOXINE HYDROCHLORIDE; ZINGIBER OFFICINALIS (GINGER) EXT&DERIV FOCALGIN-B CALCIUM; CALCIUM 124.23MG; 0; 0; 1.22MG; TABS None Female 60 30 PHOSPHATE DIBASIC; 42MG; 100MG CALCIUM PHOSPHATE TRIBASIC; FOLIC ACID; PYRIDOXINE HYDROCHLORIDE; ZINGIBER OFFICINALIS (GINGER) EXT&DERIV SALONPAS CAMPHOR; MENTHOL; 1.2%; 5.7%; 6.3% PTCH Min Age: 18Y None 40 30 METHYL SALICYLATE CANDESARTAN CILEXETIL CANDESARTAN CILEXETIL 4MG TABS Min Age: 21Y None PA required Call (888) 989-0091. For members age 0-21 BILL CCS CANDESARTAN CILEXETIL CANDESARTAN CILEXETIL 8MG TABS Min Age: 21Y None PA required Call (888) 989-0091. For members age 0-21 BILL CCS CANDESARTAN CILEXETIL CANDESARTAN CILEXETIL 16MG TABS Min Age: 21Y None PA required Call (888) 989-0091. For members age 0-21 BILL CCS

Page 60 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message CANDESARTAN CILEXETIL CANDESARTAN CILEXETIL 32MG TABS Min Age: 21Y None PA required Call (888) 989-0091. For members age 0-21 BILL CCS CANDESARTAN CANDESARTAN CILEXETIL; 32MG; 25MG TABS Min Age: 21Y None AGE 0-21 BILL CILEXETIL/HYDROCHLOROTHIAZ HYDROCHLOROTHIAZIDE CCS IDE CANDESARTAN CANDESARTAN CILEXETIL; 16MG; 12.5MG TABS Min Age: 21Y None PA required Call CILEXETIL/HYDROCHLOROTHIAZ HYDROCHLOROTHIAZIDE (888) 989-0091. IDE For members age 0-21 BILL CCS CANDESARTAN CANDESARTAN CILEXETIL; 32MG; 12.5MG TABS Min Age: 21Y None PA required Call CILEXETIL/HYDROCHLOROTHIAZ HYDROCHLOROTHIAZIDE (888) 989-0091. IDE For members age 0-21 BILL CCS CAPSAICIN HP CAPSAICIN 0.1% CREA None None 42.5 30 CAPTOPRIL CAPTOPRIL 100MG TABS Min Age: 21Y None AGE 0-21 BILL CCS CAPTOPRIL CAPTOPRIL 25MG TABS Min Age: 21Y None AGE 0-21 BILL CCS CAPTOPRIL CAPTOPRIL 50MG TABS Min Age: 21Y None AGE 0-21 BILL CCS CAPTOPRIL CAPTOPRIL 12.5MG TABS Min Age: 21Y None AGE 0-21 BILL CCS CAPTOPRIL/HYDROCHLOROTHIA CAPTOPRIL; 25MG; 15MG TABS Min Age: 21Y None AGE 0-21 BILL ZIDE HYDROCHLOROTHIAZIDE CCS CAPTOPRIL/HYDROCHLOROTHIA CAPTOPRIL; 25MG; 25MG TABS Min Age: 21Y None AGE 0-21 BILL ZIDE HYDROCHLOROTHIAZIDE CCS CAPTOPRIL/HYDROCHLOROTHIA CAPTOPRIL; 50MG; 15MG TABS Min Age: 21Y None AGE 0-21 BILL ZIDE HYDROCHLOROTHIAZIDE CCS CAPTOPRIL/HYDROCHLOROTHIA CAPTOPRIL; 50MG; 25MG TABS Min Age: 21Y None PA required Call ZIDE HYDROCHLOROTHIAZIDE (888)989-0091. For members age 0-21 BILL CCS CARBAMAZEPINE 200MG TABS None None 180 30 CARBAMAZEPINE CARBAMAZEPINE 100MG CHEW Max Age: 12Y None 180 30 CARBAMAZEPINE ER CARBAMAZEPINE 200MG TB12 None None 60 30 CARBAMAZEPINE ER CARBAMAZEPINE 400MG TB12 None None 120 30 CARBAMAZEPINE CARBAMAZEPINE 100MG/5ML SUSP None None 1920 60 CARBIDOPA CARBIDOPA MONOHYDRATE 25MG TABS None None 30 30

CARISOPRODOL CARISOPRODOL 350MG TABS None None 120 30 Use 2 formulary muscle relaxants

CARVEDILOL CARVEDILOL 25MG TABS None None 120 30 CARVEDILOL CARVEDILOL 12.5MG TABS None None 60 30

Page 61 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message CARVEDILOL CARVEDILOL 3.125MG TABS None None 60 30 CARVEDILOL CARVEDILOL 6.25MG TABS None None 60 30 CEFACLOR CEFACLOR 125MG/5ML SUSR Max Age: 12Y None

CEFACLOR CEFACLOR 250MG/5ML SUSR Max Age: 12Y None

CEFACLOR CEFACLOR 375MG/5ML SUSR Max Age: 12Y None

CEFDINIR CEFDINIR 250MG/5ML SUSR Max Age: 12Y None CEFDINIR CEFDINIR 125MG/5ML SUSR Max Age: 12Y None

SUPRAX CEFIXIME 400MG TABS None None 28 28 SUPRAX CEFIXIME 100MG/5ML SUSR Max Age: 12Y None SUPRAX CEFIXIME 200MG/5ML SUSR Max Age: 12Y None

CEFPODOXIME PROXETIL CEFPODOXIME PROXETIL 100MG TABS None None 60 30 CEFPODOXIME PROXETIL CEFPODOXIME PROXETIL 50MG/5ML SUSR Max Age: 12Y None

CEFPODOXIME PROXETIL CEFPODOXIME PROXETIL 100MG/5ML SUSR None Max Age: 12Y CEFPROZIL CEFPROZIL 125MG/5ML SUSR Max Age: 12Y None CEFPROZIL CEFPROZIL 250MG/5ML SUSR Max Age: 12Y None

CEFTIN CEFUROXIME AXETIL 250MG/5ML SUSR Max Age: 12Y None CEFUROXIME AXETIL CEFUROXIME AXETIL 125MG/5ML SUSR Max Age: 12Y None CELEBREX CELECOXIB 400MG CAPS None None 30 30 Try and fail 2 formulary NSAIDs CELEBREX CELECOXIB 100MG CAPS None None 60 30 Try and fail 2 formulary NSAIDs CELEBREX CELECOXIB 200MG CAPS None None 60 30 Try and fail 2 formulary NSAIDs CELEBREX CELECOXIB 50MG CAPS None None 60 30 Try and fail 2 formulary NSAIDs CHLORTHALIDONE CHLORTHALIDONE 100MG TABS None None 30 30 CHLORTHALIDONE CHLORTHALIDONE 25MG TABS None None 30 30 CHLORTHALIDONE CHLORTHALIDONE 50MG TABS None None 30 30 PRENA1 CHEW/QUATREFOLIC CHOLECALCIFEROL; FOLIC 400UNIT; 400MCG; 600MCG; CHEW None Female 30 30 ACID; LEVOMEFOLATE 8MCG; 2MG; 1.7MG GLUCOSAMINE (QUATREFOLIC); METHYLCOBALAMIN (MECOBALAMIN); PYRIDOXINE HYDROCHLORIDE; RIBOFLAVIN

Page 62 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message CHOLESTYRAMINE LIGHT CHOLESTYRAMINE 4GM PACK Min Age: 21Y None AGE 0-21 BILL CCS CHOLESTYRAMINE CHOLESTYRAMINE 4GM PACK Min Age: 21Y None AGE 0-21 BILL CCS CHOLESTYRAMINE CHOLESTYRAMINE 4GM/DOSE POWD Min Age: 21Y None AGE 0-21 BILL CCS CHOLESTYRAMINE LIGHT CHOLESTYRAMINE 4GM/DOSE POWD Min Age: 21Y None AGE 0-21 BILL CCS CICLOPIROX OLAMINE CICLOPIROX OLAMINE 0.77% CREA None None 90 30 CILOSTAZOL CILOSTAZOL 100MG TABS None None 60 30 CILOSTAZOL CILOSTAZOL 50MG TABS None None 60 30 SENSIPAR CINACALCET 30MG TABS None None 30 30 HYDROCHLORIDE SENSIPAR CINACALCET 60MG TABS None None 60 30 HYDROCHLORIDE SENSIPAR CINACALCET 90MG TABS None None 60 30 HYDROCHLORIDE CIPRODEX CIPROFLOXACIN HCL; 0.3%; 0.1% SUSP None None 7.5 30 Use ciprofloxacin DEXAMETHASONE or ofloxacin otic

CIPROFLOXACIN ER CIPROFLOXACIN; 1000MG; 0 TB24 None None 30 30 CIPROFLOXACIN HCL CITALOPRAM HYDROBROMIDE CITALOPRAM HYDROBROMIDE 20MG TABS None None 45 30

CITALOPRAM HYDROBROMIDE CITALOPRAM HYDROBROMIDE 40MG TABS None None 30 30

CITALOPRAM HYDROBROMIDE CITALOPRAM HYDROBROMIDE 10MG TABS None None 45 30

CLARITHROMYCIN CLARITHROMYCIN 500MG TABS None None 28 14 Member allowed 2 fills per year

CLARITHROMYCIN CLARITHROMYCIN 250MG TABS None None 28 14 Member allowed 2 fills per year

CLINDAMYCIN PALMITATE HCL CLINDAMYCIN PALMITATE 75MG/5ML SOLR Max Age: 12Y None HCL CLONIDINE HCL CLONIDINE HYDROCHLORIDE 0.1MG/24HR PTWK Min Age: 21Y None Use PO clonidine. PA required Call (888) 989-0091. For members age 0-21 BILL CCS. CLONIDINE HCL CLONIDINE HYDROCHLORIDE 0.2MG/24HR PTWK Min Age: 21Y None Use PO clonidine. PA required Call (888) 989-0091. For members age 0-21 BILL CCS.

Page 63 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message CLONIDINE HCL CLONIDINE HYDROCHLORIDE 0.3MG/24HR PTWK Min Age: 21Y None Use PO clonidine. PA required Call (888) 989-0091. For members age 0-21 BILL CCS. CLONIDINE HCL ER CLONIDINE HYDROCHLORIDE 0.1MG TB12 Min Age: 5Y None Max Age: 24Y KAPVAY DOSE PACK CLONIDINE HYDROCHLORIDE 0 MISC Min Age: 5Y None Max Age: 24Y

CLOTRIMAZOLE CLOTRIMAZOLE 1% CREA None None 180 30 CODEINE SULFATE CODEINE SULFATE 15MG TABS None None 120 30 CODEINE SULFATE CODEINE SULFATE 30MG TABS None None 120 30 CODEINE SULFATE CODEINE SULFATE 60MG TABS None None 120 30 COLCRYS COLCHICINE 0.6MG TABS None None 30 30 Member allowed 3 fills per year.

CORTISONE ACETATE CORTISONE ACETATE 25MG TABS Min Age: 21Y None AGE 0-21 BILL CCS CROMOLYN SODIUM CROMOLYN SODIUM 5.2MG/ACT AERS Min Age: 2Y None

VITAMIN B-12 CYANOCOBALAMIN 100MCG TABS None None 100 30 CYANOCOBALAMIN CYANOCOBALAMIN 1000MCG/ML SOLN None None 1 30 CYCLOBENZAPRINE HCL CYCLOBENZAPRINE 5MG TABS None None 90 30 HYDROCHLORIDE CYCLOBENZAPRINE HCL CYCLOBENZAPRINE 10MG TABS None None 90 30 HYDROCHLORIDE CYCLOSPORINE MODIFIED CYCLOSPORINE 25MG CAPS Min Age: 21Y None 120 30 AGE 0-21 BILL CCS CYCLOSPORINE MODIFIED CYCLOSPORINE 100MG CAPS Min Age: 21Y None 120 30 AGE 0-21 BILL CCS CYCLOSPORINE MODIFIED CYCLOSPORINE 50MG CAPS Min Age: 21Y None Use cyclosporine modified 25 mg; AGE 0-21 BILL CCS

DESMOPRESSIN ACETATE DESMOPRESSIN ACETATE 0.1MG TABS Min Age: 7 Y None 30 30 Max Age: 18Y

DESMOPRESSIN ACETATE DESMOPRESSIN ACETATE 0.2MG TABS Min Age: 7Y None 90 30 Max Age: 18Y

VELIVET DESOGESTREL; ETHINYL 0; 0 TABS None Female 30 30 ESTRADIOL RECLIPSEN DESOGESTREL; ETHINYL 0.15MG; 30MCG TABS None Female 30 30 ESTRADIOL VIORELE DESOGESTREL; ETHINYL 0; 0 TABS None Female 30 30 ESTRADIOL DESOXIMETASONE DESOXIMETASONE 0.25% CREA None None 60 30

Page 64 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message TOBRAMYCIN/DEXAMETHASONE DEXAMETHASONE; 0.1%; 0.3% SUSP None None 5 30 TOBRAMYCIN SULFATE DEXMETHYLPHENIDATE HCL DEXMETHYLPHENIDATE 2.5MG TABS Min Age: 5Y None 60 30 HYDROCHLORIDE Max Age: 18Y DEXMETHYLPHENIDATE HCL DEXMETHYLPHENIDATE 5MG TABS Min Age: 5Y None 60 30 HYDROCHLORIDE Max Age: 18Y

DEXMETHYLPHENIDATE HCL DEXMETHYLPHENIDATE 10MG TABS Min Age: 5Y None 60 30 HYDROCHLORIDE Max Age: 18Y DEXTROAMPHETAMINE SULFATE DEXTROAMPHETAMINE 5MG TABS Min Age: 5Y None 60 30 SULFATE Max Age: 18Y KETOSTIX DIAGNOSTIC TEST 0 STRP None None 100 100 DIASTAT ACUDIAL DIAZEPAM 10MG GEL None None 3 365 Member allowed 3 fills per year

DIAZEPAM DIAZEPAM 20MG GEL None None 3 365 Member allowed 3 fills per year

DIAZEPAM DIAZEPAM 2.5MG GEL None None 3 365 Member allowed 3 fills per year

VIDEX PEDIATRIC DIDANOSINE 2GM SOLR Min Age: 21Y None AGE 0-21 BILL CCS DIDANOSINE DIDANOSINE 400MG CPDR Min Age: 21Y None AGE 0-21 BILL CCS DIDANOSINE DIDANOSINE 125MG CPDR Min Age: 21Y None AGE 0-21 BILL CCS DIDANOSINE DIDANOSINE 200MG CPDR Min Age: 21Y None AGE 0-21 BILL CCS DUREZOL DIFLUPREDNATE 0.05% EMUL None None 5 30 DIGOXIN DIGOXIN 0.05MG/ML SOLN Min Age: 21Y None AGE 0-21 BILL CCS DIGOXIN DIGOXIN 125MCG TABS Min Age: 21Y None AGE 0-21 BILL CCS DIGOXIN DIGOXIN 250MCG TABS Min Age: 21Y None AGE 0-21 BILL CCS DILTIAZEM HCL ER DILTIAZEM HYDROCHLORIDE 120MG CP12 Min Age: 21Y None 30 30 AGE 0-21 BILL CCS DILTIAZEM CD DILTIAZEM HYDROCHLORIDE 180MG CP24 Min Age: 21Y None 30 30 AGE 0-21 BILL CCS DILTIAZEM HCL ER DILTIAZEM HYDROCHLORIDE 240MG CP24 Min Age: 21Y None 30 30 AGE 0-21 BILL CCS DILTIAZEM HCL ER DILTIAZEM HYDROCHLORIDE 300MG CP24 Min Age: 21Y None 30 30 AGE 0-21 BILL CCS DILTIAZEM HCL ER DILTIAZEM HYDROCHLORIDE 120MG CP24 Min Age: 21Y None 30 30 AGE 0-21 BILL CCS DILTIAZEM HCL ER DILTIAZEM HYDROCHLORIDE 360MG CP24 Min Age: 21Y None 30 30 AGE 0-21 BILL CCS DILTIAZEM HCL ER DILTIAZEM HYDROCHLORIDE 180MG CP24 Min Age: 21Y None 30 30 AGE 0-21 BILL CCS

Page 65 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message TAZTIA XT DILTIAZEM HYDROCHLORIDE 120MG CP24 None None 30 30

DILTIAZEM HCL ER DILTIAZEM HYDROCHLORIDE 300MG CP24 Min Age: 21Y None 30 30 AGE 0-21 BILL CCS DILTIAZEM HCL ER DILTIAZEM HYDROCHLORIDE 360MG CP24 Min Age: 21Y None 30 30 AGE 0-21 BILL CCS DILTIAZEM HCL ER DILTIAZEM HYDROCHLORIDE 180MG CP24 Min Age: 21Y None 30 30 AGE 0-21 BILL CCS DILTIAZEM HCL ER DILTIAZEM HYDROCHLORIDE 240MG CP24 Min Age: 21Y None 30 30 AGE 0-21 BILL CCS DILTIAZEM HCL ER DILTIAZEM HYDROCHLORIDE 120MG CP24 Min Age: 21Y None 30 30 AGE 0-21 BILL CCS DILTIAZEM HCL ER DILTIAZEM HYDROCHLORIDE 90MG CP12 Min Age: 21Y None AGE 0-21 BILL CCS DILTIAZEM HCL ER DILTIAZEM HYDROCHLORIDE 60MG CP12 Min Age: 21Y None AGE 0-21 BILL CCS DILTIAZEM HCL DILTIAZEM HYDROCHLORIDE 30MG TABS Min Age: 21Y None AGE 0-21 BILL CCS DILTIAZEM HCL DILTIAZEM HYDROCHLORIDE 60MG TABS Min Age: 21Y None AGE 0-21 BILL CCS DILTIAZEM HCL DILTIAZEM HYDROCHLORIDE 90MG TABS Min Age: 21Y None AGE 0-21 BILL CCS DILTIAZEM HCL DILTIAZEM HYDROCHLORIDE 120MG TABS Min Age: 21Y None AGE 0-21 BILL CCS DIPYRIDAMOLE DIPYRIDAMOLE 25MG TABS Min Age: 21Y None AGE 0-21 BILL CCS DIPYRIDAMOLE DIPYRIDAMOLE 50MG TABS Min Age: 21Y None AGE 0-21 BILL CCS DIPYRIDAMOLE DIPYRIDAMOLE 75MG TABS Min Age: 21Y None AGE 0-21 BILL CCS NORPACE CR DISOPYRAMIDE PHOSPHATE 100MG CP12 Min Age: 21Y None AGE 0-21 BILL CCS NORPACE CR DISOPYRAMIDE PHOSPHATE 150MG CP12 Min Age: 21Y None AGE 0-21 BILL CCS DIVALPROEX SODIUM DR DIVALPROEX SODIUM 250MG TBEC None None 240 30 DIVALPROEX SODIUM DR DIVALPROEX SODIUM 500MG TBEC None None 240 30 DIVALPROEX SODIUM DR DIVALPROEX SODIUM 125MG TBEC None None 240 30 DIVALPROEX SODIUM DIVALPROEX SODIUM 125MG CPSP Max Age: 12Y None 300 30

DIVALPROEX SODIUM ER DIVALPROEX SODIUM 500MG TB24 None None 210 30 SE-TAN DHA DOCOSAHEXAENOIC ACID 215.12MG; 53.46MG; 15MG; CAPS None Female 30 30 (DHA); EICOSAPENTAENOIC 1MG; 310.1MG; 15MG; 25MG; ACID (EPA); FERROUS 20MG FUMARATE; FOLIC ACID; OMEGA-3 FATTY ACIDS; POLYSACCHARIDE IRON COMPLEX; PYRIDOXINE HYDROCHLORIDE; SODIUM ASCORBATE

Page 66 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message FISH OIL DOCOSAHEXAENOIC ACID 0; 0; 1000MG; 300MG; 1UNIT CAPS None None 120 30 (DHA); EICOSAPENTAENOIC ACID (EPA); FISH OIL; OMEGA-3 FATTY ACIDS; VITAMIN E ABREVA DOCOSANOL (N-DOCOSANOL) 10% CREA None None 2 30

DONEPEZIL HCL DONEPEZIL HYDROCHLORIDE 10MG TABS None None 30 30

DONEPEZIL HCL DONEPEZIL HYDROCHLORIDE 5MG TABS None None 30 30

DONEPEZIL HCL DONEPEZIL HYDROCHLORIDE 23MG TABS None None 30 30

DOXERCALCIFEROL DOXERCALCIFEROL 0.5MCG CAPS None None 60 30 Use calcitriol DOXERCALCIFEROL DOXERCALCIFEROL 1MCG CAPS None None 60 30 Use calcitriol DOXERCALCIFEROL DOXERCALCIFEROL 2.5MCG CAPS None None 60 30 Use calcitriol DOXYCYCLINE HYCLATE DOXYCYCLINE HYCLATE 100MG CAPS None None 60 30 DOXYCYCLINE HYCLATE DOXYCYCLINE HYCLATE 50MG CAPS None None 60 30 DOXYCYCLINE HYCLATE DOXYCYCLINE HYCLATE 100MG TABS None None 60 30 SYEDA DROSPIRENONE; ETHINYL 3MG; 0.03MG TABS None Female 30 30 ESTRADIOL GIANVI DROSPIRENONE; ETHINYL 3MG; 0.02MG TABS None Female 30 30 ESTRADIOL ECONAZOLE NITRATE ECONAZOLE NITRATE 1% CREA None None 340 30 ENALAPRIL MALEATE ENALAPRIL MALEATE 5MG TABS Min Age: 21Y None AGE 0-21 BILL CCS ENALAPRIL MALEATE ENALAPRIL MALEATE 10MG TABS Min Age: 21Y None AGE 0-21 BILL CCS ENALAPRIL MALEATE ENALAPRIL MALEATE 20MG TABS Min Age: 21Y None AGE 0-21 BILL CCS ENALAPRIL MALEATE ENALAPRIL MALEATE 2.5MG TABS Min Age: 21Y None AGE 0-21 BILL CCS ENALAPRIL ENALAPRIL MALEATE; 10MG; 25MG TABS Min Age: 21Y None AGE 0-21 BILL MALEATE/HYDROCHLOROTHIAZI HYDROCHLOROTHIAZIDE CCS DE ENALAPRIL ENALAPRIL MALEATE; 5MG; 12.5MG TABS Min Age: 21Y None AGE 0-21 BILL MALEATE/HYDROCHLOROTHIAZI HYDROCHLOROTHIAZIDE CCS DE ENOXAPARIN SODIUM ENOXAPARIN SODIUM 30MG/0.3ML SOLN None None 6 10 Member allowed 2 fills per year

ENOXAPARIN SODIUM ENOXAPARIN SODIUM 150MG/ML SOLN None None 20 10 Member allowed 2 fills per year

ENOXAPARIN SODIUM ENOXAPARIN SODIUM 120MG/0.8ML SOLN None None 16 10 Member allowed 2 fills per year

ENOXAPARIN SODIUM ENOXAPARIN SODIUM 60MG/0.6ML SOLN None None 12 10 Member allowed 2 fills per year

Page 67 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message ENOXAPARIN SODIUM ENOXAPARIN SODIUM 80MG/0.8ML SOLN None None 16 10 Member allowed 2 fills per year

ENOXAPARIN SODIUM ENOXAPARIN SODIUM 100MG/ML SOLN None None 20 10 Member allowed 2 fills per year

ENOXAPARIN SODIUM ENOXAPARIN SODIUM 40MG/0.4ML SOLN None None 8 10 Member allowed 2 fills per year

ENOXAPARIN SODIUM ENOXAPARIN SODIUM 300MG/3ML SOLN None None 6 10 Member allowed 2 fills per year

EPINASTINE HCL EPINASTINE HYDROCHLORIDE 0.05% SOLN None None 5 30 Use ketotifen

EPROSARTAN MESYLATE EPROSARTAN MESYLATE 600MG TABS Min Age: 21Y None PA required Call (888) 989-0091. For members age 0-21 BILL CCS ESCITALOPRAM OXALATE ESCITALOPRAM OXALATE 10MG TABS None None 45 30 ESCITALOPRAM OXALATE ESCITALOPRAM OXALATE 20MG TABS None None 60 30 ESCITALOPRAM OXALATE ESCITALOPRAM OXALATE 5MG TABS None None 45 30 ESCITALOPRAM OXALATE ESCITALOPRAM OXALATE 5MG/5ML SOLN Max Age: 12Y None 600 30 NEXIUM 24HR ESOMEPRAZOLE MAGNESIUM 20MG CPDR None None 56 28 Use Omeprazole TRIHYDRATE and Pantoprazole first

ESTRADIOL ESTRADIOL 0.06MG/24HR PTWK None Female 4 28

ESTRADIOL ESTRADIOL 37.5MCG/24HR PTWK None Female 4 28

MENOSTAR ESTRADIOL 14MCG/24HR PTWK None None 4 28 VIVELLE-DOT ESTRADIOL 0.05MG/24HR PTTW None None 24 84 VIVELLE-DOT ESTRADIOL 0.1MG/24HR PTTW None None 24 84 VIVELLE-DOT ESTRADIOL 0.075MG/24HR PTTW None None 24 84 ESTRADIOL ESTRADIOL 0.1MG/24HR PTWK None Female 4 28

ESTRADIOL ESTRADIOL 0.05MG/24HR PTWK None Female 4 28

VIVELLE-DOT ESTRADIOL 0.0375MG/24HR PTTW None None 24 84 ESTRADIOL ESTRADIOL 0.025MG/24HR PTWK None Female 4 28

ESTRADIOL ESTRADIOL 0.075MG/24HR PTWK None Female 4 28

DEPO-ESTRADIOL ESTRADIOL CYPIONATE 5MG/ML OIL None None 10 90 ESTRADIOL VALERATE ESTRADIOL VALERATE 20MG/ML OIL None None 10 80 ESTRADIOL VALERATE ESTRADIOL VALERATE 10MG/ML OIL None None 10 80 ESTRADIOL VALERATE ESTRADIOL VALERATE 40MG/ML OIL None None 10 80

Page 68 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message CLIMARA PRO ESTRADIOL; 0.045MG/DAY; 0.015MG/DAY PTWK None Female 4 28 LEVONORGESTREL COMBIPATCH ESTRADIOL; 0.05MG/DAY; 0.14MG/DAY PTTW None None 8 28 NORETHINDRONE ACETATE COMBIPATCH ESTRADIOL; 0.05MG/DAY; 0.25MG/DAY PTTW None None 8 28 NORETHINDRONE ACETATE KELNOR 1/35 ETHINYL ESTRADIOL; 35MCG; 1MG TABS None Female 30 30 ETHYNODIOL DIACETATE ZOVIA 1/50E ETHINYL ESTRADIOL; 50MCG; 1MG TABS None Female 30 30 ETHYNODIOL DIACETATE NUVARING ETHINYL ESTRADIOL; 0.015MG/24HR; 0.12MG/24HR RING None Female 1 30 ETONOGESTREL GENERESS FE ETHINYL ESTRADIOL; 25MCG; 75MG; 0.8MG CHEW None Female 30 30 FERROUS FUMARATE; NORETHINDRONE ZENCHENT FE ETHINYL ESTRADIOL; 35MCG; 0; 0.4MG CHEW None Female 30 30 FERROUS FUMARATE; NORETHINDRONE JUNEL FE 1.5/30 ETHINYL ESTRADIOL; 30MCG; 75MG; 1.5MG TABS None Female 30 30 FERROUS FUMARATE; NORETHINDRONE ACETATE JUNEL FE 1/20 ETHINYL ESTRADIOL; 20MCG; 75MG; 1MG TABS None Female 30 30 FERROUS FUMARATE; NORETHINDRONE ACETATE TRI-LEGEST FE ETHINYL ESTRADIOL; 0; 75MG; 1MG TABS None Female 30 30 FERROUS FUMARATE; NORETHINDRONE ACETATE CHATEAL ETHINYL ESTRADIOL; 0.03MG; 0.15MG TABS None Female 30 30 LEVONORGESTREL MYZILRA ETHINYL ESTRADIOL; 0; 0 TABS None Female 30 30 LEVONORGESTREL FALMINA ETHINYL ESTRADIOL; 20MCG; 0.1MG TABS None Female 30 30 LEVONORGESTREL CAMRESE LO ETHINYL ESTRADIOL; 0; 0 TABS None Female 30 30 PA Required LEVONORGESTREL JOLESSA ETHINYL ESTRADIOL; 0.03MG; 0.15MG TABS None Female 30 30 LEVONORGESTREL AMETHYST ETHINYL ESTRADIOL; 20MCG; 90MCG TABS None Female 30 30 LEVONORGESTREL PHILITH ETHINYL ESTRADIOL; 35MCG; 0.4MG TABS None Female 30 30 NORETHINDRONE NORTREL 0.5/35 (28) ETHINYL ESTRADIOL; 35MCG; 0.5MG TABS None Female 30 30 NORETHINDRONE CYCLAFEM 1/35 ETHINYL ESTRADIOL; 35MCG; 1MG TABS None Female 30 30 NORETHINDRONE NECON 10/11-28 ETHINYL ESTRADIOL; 35MCG; 0 TABS None Female 30 30 NORETHINDRONE NORTREL 7/7/7 ETHINYL ESTRADIOL; 0; 0 TABS None Female 30 30 NORETHINDRONE LEENA ETHINYL ESTRADIOL; 0; 0 TABS None Female 30 30 NORETHINDRONE

Page 69 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message MICROGESTIN 1.5/30 ETHINYL ESTRADIOL; 30MCG; 1.5MG TABS None Female 30 30 NORETHINDRONE ACETATE MICROGESTIN 1/20 ETHINYL ESTRADIOL; 20MCG; 1MG TABS None Female 30 30 NORETHINDRONE ACETATE MONONESSA ETHINYL ESTRADIOL; 35MCG; 0.25MG TABS None Female 30 30 NORGESTIMATE TRI-SPRINTEC ETHINYL ESTRADIOL; 0; 0 TABS None Female 30 30 NORGESTIMATE CRYSELLE-28 ETHINYL ESTRADIOL; 30MCG; 0.3MG TABS None Female 30 30 NORGESTREL OGESTREL ETHINYL ESTRADIOL; 50MCG; 0.5MG TABS None Female 30 30 NORGESTREL ETHOSUXIMIDE ETHOSUXIMIDE 250MG CAPS None None 180 30 ETHOSUXIMIDE ETHOSUXIMIDE 250MG/5ML SOLN None None 300 30 VYTORIN EZETIMIBE; SIMVASTATIN 10MG; 10MG TABS Min Age: 21Y None PA Required call (888) 989-0091. For members age 0-21 BILL CCS VYTORIN EZETIMIBE; SIMVASTATIN 10MG; 20MG TABS Min Age: 21Y None PA Required call (888) 989-0091. For members age 0-21 BILL CCS VYTORIN EZETIMIBE; SIMVASTATIN - 10MG; 80MG TABS Min Age: 21Y None PA Required call HIGH DOSE (40 MG & (888) 989-0091. HIGHER) For members age 0-21 BILL CCS VYTORIN EZETIMIBE; SIMVASTATIN - 10MG; 40MG TABS Min Age: 21Y None PA Required call HIGH DOSE (40 MG & (888) 989-0091. HIGHER) For members age 0-21 BILL CCS FELODIPINE ER FELODIPINE 2.5MG TB24 Min Age: 21Y None 30 30 AGE 0-21 BILL CCS FELODIPINE ER FELODIPINE 5MG TB24 Min Age: 21Y None 30 30 AGE 0-21 BILL CCS FELODIPINE ER FELODIPINE 10MG TB24 Min Age: 21Y None 60 30 AGE 0-21 BILL CCS FERROUS DROPS FERROUS SULFATE 15MG/ML SOLN None None 100 30 ALLEGRA ALLERGY CHILDRENS FEXOFENADINE 30MG TABS None None 60 30 HYDROCHLORIDE FEXOFENADINE HCL FEXOFENADINE 60MG TABS None None 60 30 HYDROCHLORIDE FEXOFENADINE HCL FEXOFENADINE 180MG TABS None None 30 30 HYDROCHLORIDE FINASTERIDE FINASTERIDE 5MG TABS None None 30 30 FISH OIL FISH OIL 1000MG CAPS None None 120 30 FLUDROCORTISONE ACETATE FLUDROCORTISONE ACETATE 0.1MG TABS Min Age: 21Y None AGE 0-21 BILL CCS

Page 70 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message FLUNISOLIDE FLUNISOLIDE 0.025% SOLN None None 25 30 FLUOCINOLONE ACETONIDE FLUOCINOLONE ACETONIDE 0.025% CREA None None 240 30

FLUOCINONIDE FLUOCINONIDE 0.05% GEL None None 240 30 FLUOCINONIDE FLUOCINONIDE 0.05% OINT None None 240 30 FLUOCINONIDE FLUOCINONIDE 0.05% SOLN None None 240 30 FLUOROURACIL FLUOROURACIL 5% CREA None None 1 365 Member allowed 1 fill per year

FLUOXETINE HCL FLUOXETINE HCL 10MG CAPS None None 30 30 FLUOXETINE FLUOXETINE HCL 20MG CAPS None None 90 30 FLUOXETINE HCL FLUOXETINE HCL 40MG CAPS None None 60 30 FLUOXETINE HCL FLUOXETINE HCL 10MG TABS None None 45 30 FLUOXETINE HCL FLUOXETINE HCL 20MG/5ML SOLN None None 150 30 FLURAZEPAM HCL FLURAZEPAM 15MG CAPS None None 15 30 HYDROCHLORIDE FLURAZEPAM HCL FLURAZEPAM 30MG CAPS None None 15 30 HYDROCHLORIDE FLOVENT DISKUS FLUTICASONE PROPIONATE 100MCG/BLIST AEPB None None 120 30

FLOVENT DISKUS FLUTICASONE PROPIONATE 250MCG/BLIST AEPB None None 120 30

FLOVENT DISKUS FLUTICASONE PROPIONATE 50MCG/BLIST AEPB None None 120 30

FLOVENT HFA FLUTICASONE PROPIONATE 110MCG/ACT AERO None None 24 30

FLOVENT HFA FLUTICASONE PROPIONATE 44MCG/ACT AERO None None 21.2 30

FLOVENT HFA FLUTICASONE PROPIONATE 220MCG/ACT AERO None None 24 30

FLUTICASONE PROPIONATE FLUTICASONE PROPIONATE 0.05% CREA None None 60 30

FLUVASTATIN FLUVASTATIN SODIUM 20MG CAPS Min Age: 21Y None PA Required call (888) 989-0091. For members age 0-21 BILL CCS FLUVASTATIN FLUVASTATIN SODIUM 40MG CAPS Min Age: 21Y None PA Required call (888) 989-0091. For members age 0-21 BILL CCS FLUVOXAMINE MALEATE FLUVOXAMINE MALEATE 25MG TABS None None 30 30 FONDAPARINUX SODIUM FONDAPARINUX SODIUM 2.5MG/0.5ML SOLN None None 5 10 Member allowed 2 fills per year

FONDAPARINUX SODIUM FONDAPARINUX SODIUM 5MG/0.4ML SOLN None None 4 10 Member allowed 2 fills per year

Page 71 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message FONDAPARINUX SODIUM FONDAPARINUX SODIUM 7.5MG/0.6ML SOLN None None 6 10 Member allowed 2 fills per year

FONDAPARINUX SODIUM FONDAPARINUX SODIUM 10MG/0.8ML SOLN None None 8 10 Member allowed 2 fills per year

DULERA FORMOTEROL FUMARATE 5MCG/ACT; 100MCG/ACT AERO None None 13 30 DIHYDRATE; MOMETASONE FUROATE DULERA FORMOTEROL FUMARATE 5MCG/ACT; 200MCG/ACT AERO None None 13 30 DIHYDRATE; MOMETASONE FUROATE FOSINOPRIL SODIUM FOSINOPRIL SODIUM 40MG TABS Min Age: 21Y None AGE 0-21 BILL CCS FOSINOPRIL SODIUM FOSINOPRIL SODIUM 10MG TABS Min Age: 21Y None AGE 0-21 BILL CCS FOSINOPRIL SODIUM FOSINOPRIL SODIUM 20MG TABS Min Age: 21Y None AGE 0-21 BILL CCS FOSINOPRIL FOSINOPRIL SODIUM; 20MG; 12.5MG TABS Min Age: 21Y None AGE 0-21 BILL SODIUM/HYDROCHLOROTHIAZI HYDROCHLOROTHIAZIDE CCS DE FOSINOPRIL FOSINOPRIL SODIUM; 10MG; 12.5MG TABS Min Age: 21Y None AGE 0-21 BILL SODIUM/HYDROCHLOROTHIAZI HYDROCHLOROTHIAZIDE CCS DE FUROSEMIDE FUROSEMIDE 10MG/ML SOLN Min Age: 21Y None AGE 0-21 BILL CCS FUROSEMIDE FUROSEMIDE 8MG/ML SOLN Min Age: 21Y None AGE 0-21 BILL CCS FUROSEMIDE FUROSEMIDE 20MG TABS Min Age: 21Y None AGE 0-21 BILL CCS FUROSEMIDE FUROSEMIDE 40MG TABS Min Age: 21Y None AGE 0-21 BILL CCS FUROSEMIDE FUROSEMIDE 80MG TABS Min Age: 21Y None AGE 0-21 BILL CCS GABAPENTIN GABAPENTIN 100MG CAPS None None 180 30 GABAPENTIN GABAPENTIN 300MG CAPS None None 360 30 GABAPENTIN GABAPENTIN 400MG CAPS None None 270 30 GABAPENTIN GABAPENTIN 250MG/5ML SOLN Max Age: 12Y None 2160 30 GABAPENTIN GABAPENTIN 800MG TABS None None 120 30 GABAPENTIN GABAPENTIN 600MG TABS None None 180 30 GEMFIBROZIL GEMFIBROZIL 600MG TABS Min Age: 21Y None AGE 0-21 BILL CCS GLIMEPIRIDE GLIMEPIRIDE 1MG TABS None None 120 30 GLIMEPIRIDE GLIMEPIRIDE 2MG TABS None None 120 30 GLIMEPIRIDE GLIMEPIRIDE 4MG TABS None None 120 30 GLIPIZIDE GLIPIZIDE 5MG TABS Min Age: 21Y None AGE 0-21 BILL CCS GLIPIZIDE GLIPIZIDE 10MG TABS Min Age: 21Y None AGE 0-21 BILL CCS GLIPIZIDE ER GLIPIZIDE 10MG TB24 Min Age: 21Y None AGE 0-21 BILL CCS

Page 72 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message GLIPIZIDE ER GLIPIZIDE 5MG TB24 Min Age: 21Y None AGE 0-21 BILL CCS GLIPIZIDE ER GLIPIZIDE 2.5MG TB24 Min Age: 21Y None AGE 0-21 BILL CCS GLIPIZIDE/METFORMIN HCL GLIPIZIDE; METFORMIN 2.5MG; 250MG TABS None None 120 30 HYDROCHLORIDE GLIPIZIDE/METFORMIN HCL GLIPIZIDE; METFORMIN 2.5MG; 500MG TABS None None 120 30 HYDROCHLORIDE GLIPIZIDE/METFORMIN HCL GLIPIZIDE; METFORMIN 5MG; 500MG TABS None None 120 30 HYDROCHLORIDE GLYBURIDE GLYBURIDE 5MG TABS Min Age: 21Y None 120 30 AGE 0-21 BILL CCS GLYBURIDE GLYBURIDE 1.25MG TABS Min Age: 21Y None AGE 0-21 BILL CCS GLYBURIDE GLYBURIDE 2.5MG TABS Min Age: 21Y None AGE 0-21 BILL CCS GLYBURIDE MICRONIZED GLYBURIDE 1.5MG TABS Min Age: 21Y None AGE 0-21 BILL CCS GLYBURIDE MICRONIZED GLYBURIDE 3MG TABS Min Age: 21Y None AGE 0-21 BILL CCS GLYBURIDE MICRONIZED GLYBURIDE 6MG TABS Min Age: 21Y None AGE 0-21 BILL CCS GLYBURIDE/METFORMIN HCL GLYBURIDE; METFORMIN 1.25MG; 250MG TABS Min Age: 21Y None 240 30 AGE 0-21 BILL HYDROCHLORIDE CCS GLYBURIDE/METFORMIN HCL GLYBURIDE; METFORMIN 2.5MG; 500MG TABS Min Age: 21Y None 120 30 AGE 0-21 BILL HYDROCHLORIDE CCS GLYBURIDE/METFORMIN HCL GLYBURIDE; METFORMIN 5MG; 500MG TABS Min Age: 21Y None AGE 0-21 BILL HYDROCHLORIDE CCS GUANFACINE HCL GUANFACINE HCL 1MG TABS None None 30 30 GUANFACINE HCL GUANFACINE HCL 2MG TABS None None 30 30 HALOBETASOL PROPIONATE HALOBETASOL PROPIONATE 0.05% OINT None None 60 30

HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE 12.5MG CAPS Min Age: 21Y None AGE 0-21 BILL CCS HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE 25MG TABS Min Age: 21Y None AGE 0-21 BILL CCS HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE 50MG TABS Min Age: 21Y None AGE 0-21 BILL CCS IRBESARTAN/HYDROCHLOROTH HYDROCHLOROTHIAZIDE; 12.5MG; 150MG TABS Min Age: 21Y None PA required Call IAZIDE IRBESARTAN (888) 989-0091. For members age 0-21 BILL CCS IRBESARTAN/HYDROCHLOROTH HYDROCHLOROTHIAZIDE; 12.5MG; 300MG TABS Min Age: 21Y None PA required Call IAZIDE IRBESARTAN (888) 989-0091. For members age 0-21 BILL CCS LISINOPRIL/HYDROCHLOROTHI HYDROCHLOROTHIAZIDE; 12.5MG; 20MG TABS Min Age: 21Y None AGE 0-21 BILL AZIDE LISINOPRIL CCS

Page 73 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message LISINOPRIL/HYDROCHLOROTHI HYDROCHLOROTHIAZIDE; 25MG; 20MG TABS Min Age: 21Y None AGE 0-21 BILL AZIDE LISINOPRIL CCS LISINOPRIL/HYDROCHLOROTHI HYDROCHLOROTHIAZIDE; 12.5MG; 10MG TABS Min Age: 21Y None AGE 0-21 BILL AZIDE LISINOPRIL CCS LOSARTAN HYDROCHLOROTHIAZIDE; 12.5MG; 50MG TABS Min Age: 21Y None 30 30 AGE 0-21 BILL POTASSIUM/HYDROCHLOROTHI LOSARTAN POTASSIUM CCS AZIDE LOSARTAN HYDROCHLOROTHIAZIDE; 25MG; 100MG TABS Min Age: 21Y None 30 30 AGE 0-21 BILL POTASSIUM/HYDROCHLOROTHI LOSARTAN POTASSIUM CCS AZIDE LOSARTAN HYDROCHLOROTHIAZIDE; 12.5MG; 100MG TABS Min Age: 21Y None 30 30 AGE 0-21 BILL POTASSIUM/HYDROCHLOROTHI LOSARTAN POTASSIUM CCS AZIDE MOEXIPRIL/HYDROCHLOROTHIA HYDROCHLOROTHIAZIDE; 12.5MG; 15MG TABS Min Age: 21Y None AGE 0-21 BILL ZIDE MOEXIPRIL HYDROCHLORIDE CCS

MOEXIPRIL/HYDROCHLOROTHIA HYDROCHLOROTHIAZIDE; 25MG; 15MG TABS Min Age: 21Y None AGE 0-21 BILL ZIDE MOEXIPRIL HYDROCHLORIDE CCS

MOEXIPRIL/HYDROCHLOROTHIA HYDROCHLOROTHIAZIDE; 12.5MG; 7.5MG TABS Min Age: 21Y None AGE 0-21 BILL ZIDE MOEXIPRIL HYDROCHLORIDE CCS

QUINAPRIL/HYDROCHLOROTHIA HYDROCHLOROTHIAZIDE; 12.5MG; 10MG TABS Min Age: 21Y None AGE 0-21 BILL ZIDE QUINAPRIL HCL CCS QUINAPRIL/HYDROCHLOROTHIA HYDROCHLOROTHIAZIDE; 12.5MG; 20MG TABS Min Age: 21Y None AGE 0-21 BILL ZIDE QUINAPRIL HCL CCS QUINAPRIL/HYDROCHLOROTHIA HYDROCHLOROTHIAZIDE; 25MG; 20MG TABS Min Age: 21Y None AGE 0-21 BILL ZIDE QUINAPRIL HCL CCS SPIRONOLACTONE/HYDROCHLO HYDROCHLOROTHIAZIDE; 25MG; 25MG TABS Min Age: 21Y None AGE 0-21 BILL ROTHIAZIDE SPIRONOLACTONE CCS TELMISARTAN/HYDROCHLOROT HYDROCHLOROTHIAZIDE; 12.5MG; 40MG TABS Min Age: 21Y None PA required Call HIAZIDE TELMISARTAN (888) 989-0091. For members age 0-21 BILL CCS TELMISARTAN/HYDROCHLOROT HYDROCHLOROTHIAZIDE; 12.5MG; 80MG TABS Min Age: 21Y None PA required Call HIAZIDE TELMISARTAN (888) 989-0091. For members age 0-21 BILL CCS TELMISARTAN/HYDROCHLOROT HYDROCHLOROTHIAZIDE; 25MG; 80MG TABS Min Age: 21Y None PA required Call H TELMISARTAN (888) 989-0091. For members age 0-21 BILL CCS TRIAMTERENE/HYDROCHLOROT HYDROCHLOROTHIAZIDE; 25MG; 37.5MG CAPS Min Age: 21Y None AGE 0-21 BILL HIAZIDE TRIAMTERENE CCS TRIAMTERENE/HYDROCHLOROT HYDROCHLOROTHIAZIDE; 50MG; 75MG TABS Min Age: 21Y None AGE 0-21 BILL HIAZIDE TRIAMTERENE CCS TRIAMTERENE/HYDROCHLOROT HYDROCHLOROTHIAZIDE; 25MG; 37.5MG TABS Min Age: 21Y None AGE 0-21 BILL HIAZIDE TRIAMTERENE CCS

Page 74 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message VALSARTAN/HYDROCHLOROTHI HYDROCHLOROTHIAZIDE; 12.5MG; 80MG TABS Min Age: 21Y None Use ACEIs or AZIDE VALSARTAN losartan/HCTZ. PA required Call (888) 989-0091. For members age 0-21 BILL CCS. VALSARTAN/HYDROCHLOROTHI HYDROCHLOROTHIAZIDE; 12.5MG; 160MG TABS Min Age: 21Y None Use ACEIs or AZIDE VALSARTAN losartan/HCTZ. PA required Call (888) 989-0091. For members age 0-21 BILL CCS. VALSARTAN/HYDROCHLOROTHI HYDROCHLOROTHIAZIDE; 25MG; 160MG TABS Min Age: 21Y None Use ACEIs or AZIDE VALSARTAN losartan/HCTZ. PA required Call (888) 989-0091. For members age 0-21 BILL CCS. VALSARTAN/HYDROCHLOROTHI HYDROCHLOROTHIAZIDE; 25MG; 320MG TABS Min Age: 21Y None Use ACEIs or AZIDE VALSARTAN losartan/HCTZ. PA required Call (888) 989-0091. For members age 0-21 BILL CCS. VALSARTAN/HYDROCHLOROTHI HYDROCHLOROTHIAZIDE; 12.5MG; 320MG TABS Min Age: 21Y None Use ACEIs or AZIDE VALSARTAN losartan/HCTZ. PA required Call (888) 989-0091. For members age 0-21 BILL CCS. HYDROCORTISONE HYDROCORTISONE 1% LOTN None None 240 30 HYDROCORTISONE HYDROCORTISONE 0.5% CREA None None 240 30 HYDROCORTISONE HYDROCORTISONE 1% CREA None None 240 30 HYDROCORTISONE HYDROCORTISONE 2.5% CREA None None 240 30 HYDROCORTISONE HYDROCORTISONE 0.5% OINT None None 240 30 HYDROCORTISONE HYDROCORTISONE 1% OINT None None 240 30 HYDROCORTISONE HYDROCORTISONE 2.5% OINT None None 240 30 HYDROCORTISONE HYDROCORTISONE 2.5% LOTN None None 240 30 HYDROCORTISONE HYDROCORTISONE 1% CREA None None 240 30 HYDROCORTISONE HYDROCORTISONE 10MG TABS Min Age: 21Y None AGE 0-21 BILL CCS HYDROCORTISONE HYDROCORTISONE 20MG TABS Min Age: 21Y None AGE 0-21 BILL CCS HYDROCORTISONE HYDROCORTISONE 5MG TABS Min Age: 21Y None AGE 0-21 BILL CCS

Page 75 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message HYDROMORPHONE HCL HYDROMORPHONE 2MG TABS None None 120 30 HYDROCHLORIDE HYDROMORPHONE HCL HYDROMORPHONE 4MG TABS None None 120 30 HYDROCHLORIDE HYDROMORPHONE HCL HYDROMORPHONE 8MG TABS None None 120 30 HYDROCHLORIDE IBANDRONATE SODIUM IBANDRONATE SODIUM 150MG TABS Min Age: 21Y None 1 30 Use alendronate. For members age 0-21 BILL CCS

IMIQUIMOD IMIQUIMOD 5% CREA Min Age: 12Y None 12 30 Member allowed 4 fills per year

NOVOLOG INSULIN ASPART (HUMAN 100UNIT/ML SOLN Min Age: 21Y None AGE 0-21 BILL ANALOG) CCS NOVOLOG FLEXPEN INSULIN ASPART (HUMAN 100UNIT/ML SOPN Min Age: 21Y None AGE 0-21 BILL ANALOG) CCS NOVOLOG PENFILL INSULIN ASPART (HUMAN 100UNIT/ML SOCT Min Age: 21Y None AGE 0-21 BILL ANALOG) CCS NOVOLOG MIX 70/30 INSULIN ASPART (HUMAN 30UNIT/ML; 70UNIT/ML SUPN Min Age: 21Y None AGE 0-21 BILL PREFILLED FLEXPEN ANALOG); INSULIN ASPART CCS PROTAMINE NOVOLOG MIX 70/30 INSULIN ASPART (HUMAN 30UNIT/ML; 70UNIT/ML SUSP Min Age: 21Y None AGE 0-21 BILL ANALOG); INSULIN ASPART CCS PROTAMINE LEVEMIR FLEXPEN INSULIN DETEMIR 100UNIT/ML SOPN Min Age: 21Y None Use Lantus. For members age 0- 21 BILL CCS

LEVEMIR INSULIN DETEMIR 100UNIT/ML SOLN Min Age: 21Y None Use Lantus. For members age 0- 21 BILL CCS

LANTUS INSULIN GLARGINE 100UNIT/ML SOLN Min Age: 21Y None AGE 0-21 BILL CCS LANTUS SOLOSTAR INSULIN GLARGINE 100UNIT/ML SOPN Min Age: 21Y None AGE 0-21 BILL CCS APIDRA INSULIN GLULISINE 100UNIT/ML SOLN Min Age: 21Y None AGE 0-21 BILL CCS APIDRA SOLOSTAR INSULIN GLULISINE 100UNIT/ML SOPN Min Age: 21Y None AGE 0-21 BILL CCS HUMULIN R U-500 INSULIN HUMAN (REGULAR) 500UNIT/ML SOLN Min Age: 21Y None AGE 0-21 BILL (CONCENTRATED) CCS NOVOLIN R RELION INSULIN HUMAN (REGULAR) 100UNIT/ML SOLN Min Age: 21Y None AGE 0-21 BILL CCS HUMULIN 70/30 PEN INSULIN HUMAN (REGULAR); 30UNIT/ML; 70UNIT/ML SUPN Min Age: 21Y None AGE 0-21 BILL INSULIN HUMAN, ISOPHANE CCS (NPH)

Page 76 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message HUMULIN 70/30 INSULIN HUMAN (REGULAR); 30UNIT/ML; 70UNIT/ML SUSP Min Age: 21Y None AGE 0-21 BILL INSULIN HUMAN, ISOPHANE CCS (NPH) HUMULIN N INSULIN HUMAN, ISOPHANE 100UNIT/ML SUSP Min Age: 21Y None AGE 0-21 BILL (NPH) CCS HUMULIN N U-100 PEN INSULIN HUMAN, ISOPHANE 100UNIT/ML SUPN Min Age: 21Y None AGE 0-21 BILL (NPH) CCS HUMALOG INSULIN LISPRO 100UNIT/ML SOCT Min Age: 21Y None AGE 0-21 BILL CCS HUMALOG INSULIN LISPRO 100UNIT/ML SOLN Min Age: 21Y None AGE 0-21 BILL CCS HUMALOG KWIKPEN INSULIN LISPRO 100UNIT/ML SOPN Min Age: 21Y None AGE 0-21 BILL CCS HUMALOG MIX 75/25 INSULIN LISPRO; INSULIN 25UNIT/ML; 75UNIT/ML SUSP Min Age: 21Y None AGE 0-21 BILL LISPRO PROTAMINE (NPL) CCS HUMALOG MIX 50/50 KWIKPEN INSULIN LISPRO; INSULIN 50UNIT/ML; 50UNIT/ML SUPN Min Age: 21Y None AGE 0-21 BILL LISPRO PROTAMINE (NPL) CCS HUMALOG MIX 75/25 KWIKPEN INSULIN LISPRO; INSULIN 25UNIT/ML; 75UNIT/ML SUPN Min Age: 21Y None AGE 0-21 BILL LISPRO PROTAMINE (NPL) CCS ATROVENT HFA IPRATROPIUM BROMIDE 17MCG/ACT AERS None None 25.8 30 IPRATROPIUM BROMIDE IPRATROPIUM BROMIDE 0.02% SOLN None None 312.5 30 IPRATROPIUM BROMIDE IPRATROPIUM BROMIDE 0.06% SOLN None None 15 30 IPRATROPIUM BROMIDE IPRATROPIUM BROMIDE 0.03% SOLN None None 30 30 IRBESARTAN IRBESARTAN 150MG TABS Min Age: 21Y None Use an Ace Inhibitor and Losartan. For members age 0- 21 BILL CCS IRBESARTAN IRBESARTAN 300MG TABS Min Age: 21Y None Use an Ace Inhibitor and Losartan. For members age 0- 21 BILL CCS IRBESARTAN IRBESARTAN 75MG TABS Min Age: 21Y None Use an Ace Inhibitor and Losartan. For members age 0- 21 BILL CCS ISONIAZID ISONIAZID 50MG/5ML SYRP Max Age: 12Y None PA Required for > 12 y/o DILATRATE SR ISOSORBIDE DINITRATE 40MG CPCR Min Age: 21Y None AGE 0-21 BILL CCS ISOSORBIDE DINITRATE ISOSORBIDE DINITRATE 10MG TABS Min Age: 21Y None AGE 0-21 BILL CCS ISOSORBIDE DINITRATE ISOSORBIDE DINITRATE 20MG TABS Min Age: 21Y None AGE 0-21 BILL CCS ISOSORBIDE DINITRATE ISOSORBIDE DINITRATE 30MG TABS Min Age: 21Y None AGE 0-21 BILL CCS ISORDIL TITRADOSE ISOSORBIDE DINITRATE 40MG TABS Min Age: 21Y None AGE 0-21 BILL CCS

Page 77 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message ISOSORBIDE DINITRATE ISOSORBIDE DINITRATE 5MG TABS Min Age: 21Y None AGE 0-21 BILL CCS ISOSORBIDE DINITRATE ER ISOSORBIDE DINITRATE 40MG TBCR Min Age: 21Y None AGE 0-21 BILL CCS ISOSORBIDE MONONITRATE ISOSORBIDE MONONITRATE 20MG TABS Min Age: 21Y None AGE 0-21 BILL CCS ISOSORBIDE MONONITRATE ISOSORBIDE MONONITRATE 10MG TABS Min Age: 21Y None AGE 0-21 BILL CCS ISOSORBIDE MONONITRATE ER ISOSORBIDE MONONITRATE 60MG TB24 Min Age: 21Y None AGE 0-21 BILL CCS ISOSORBIDE MONONITRATE ER ISOSORBIDE MONONITRATE 120MG TB24 Min Age: 21Y None AGE 0-21 BILL CCS ISOSORBIDE MONONITRATE ER ISOSORBIDE MONONITRATE 30MG TB24 Min Age: 21Y None AGE 0-21 BILL CCS LABETALOL HCL LABETALOL HYDROCHLORIDE 300MG TABS Min Age: 21Y None AGE 0-21 BILL CCS LABETALOL HCL LABETALOL HYDROCHLORIDE 200MG TABS Min Age: 21Y None AGE 0-21 BILL CCS LABETALOL HCL LABETALOL HYDROCHLORIDE 100MG TABS Min Age: 21Y None AGE 0-21 BILL CCS LAMOTRIGINE 100MG TABS None None 60 30 LAMOTRIGINE LAMOTRIGINE 25MG TABS None None 150 30 LAMOTRIGINE LAMOTRIGINE 5MG CHEW Max Age: 12Y None 120 30 LAMOTRIGINE LAMOTRIGINE 150MG TABS None None 150 30 LAMOTRIGINE LAMOTRIGINE 200MG TABS None None 120 30 LAMOTRIGINE LAMOTRIGINE 25MG CHEW Max Age: 12Y None LANSOPRAZOLE LANSOPRAZOLE 15MG CPDR None None 30 30 Member must have 2 months of therapy of both omeprazole and pantoprazole

LANSOPRAZOLE LANSOPRAZOLE 30MG CPDR None None 30 30 Member must have 2 months of therapy of both omeprazole and pantoprazole

LATANOPROST LATANOPROST 0.005% SOLN Min Age: 21Y None 2.5 30 AGE 0-21 BILL CCS LEFLUNOMIDE LEFLUNOMIDE 10MG TABS None None 30 30 LEFLUNOMIDE LEFLUNOMIDE 20MG TABS None None 30 30 LEVALBUTEROL HCL LEVALBUTEROL 0.31MG/3ML NEBU None None 240 30 Use an Albuterol HYDROCHLORIDE Product

LEVALBUTEROL LEVALBUTEROL 1.25MG/0.5ML NEBU None None 150 30 Use an Albuterol HYDROCHLORIDE Product

Page 78 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message LEVALBUTEROL HCL LEVALBUTEROL 0.63MG/3ML NEBU None None 360 30 Use an Albuterol HYDROCHLORIDE Product

LEVALBUTEROL HCL LEVALBUTEROL 1.25MG/3ML NEBU None None 360 30 Use an Albuterol HYDROCHLORIDE Product

XOPENEX HFA LEVALBUTEROL TARTRATE 45MCG/ACT AERO None None 15 30 Use Ventolin HFA

LEVETIRACETAM ER LEVETIRACETAM 500MG TB24 None None 30 30 LEVETIRACETAM LEVETIRACETAM 100MG/ML SOLN Max Age: 12Y None 900 30 LEVETIRACETAM ER LEVETIRACETAM 750MG TB24 None None 30 30 LEVETIRACETAM LEVETIRACETAM 750MG TABS None None 120 30 LEVETIRACETAM LEVETIRACETAM 250MG TABS None None 60 30 LEVETIRACETAM LEVETIRACETAM 500MG TABS None None 180 30 LEVETIRACETAM LEVETIRACETAM 1000MG TABS None None 90 30 LEVOFLOXACIN LEVOFLOXACIN 250MG TABS None None 30 30 HEMIHYDRATE LEVOFLOXACIN LEVOFLOXACIN 500MG TABS None None 30 30 HEMIHYDRATE LEVOFLOXACIN LEVOFLOXACIN 750MG TABS None None 30 30 HEMIHYDRATE NEXT CHOICE ONE DOSE LEVONORGESTREL 1.5MG TABS None Female 1 30 Member allowed 6 fills per year

LEVONORGESTREL LEVONORGESTREL 0.75MG TABS None Female 2 30 Member allowed 6 fills per year

LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM 112MCG TABS Min Age: 21Y None AGE 0-21 BILL CCS LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM 25MCG TABS Min Age: 21Y None AGE 0-21 BILL CCS LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM 50MCG TABS Min Age: 21Y None AGE 0-21 BILL CCS LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM 100MCG TABS Min Age: 21Y None AGE 0-21 BILL CCS LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM 75MCG TABS Min Age: 21Y None AGE 0-21 BILL CCS LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM 200MCG TABS Min Age: 21Y None AGE 0-21 BILL CCS LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM 125MCG TABS Min Age: 21Y None AGE 0-21 BILL CCS LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM 150MCG TABS Min Age: 21Y None AGE 0-21 BILL CCS LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM 175MCG TABS Min Age: 21Y None AGE 0-21 BILL CCS LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM 300MCG TABS Min Age: 21Y None AGE 0-21 BILL CCS LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM 88MCG TABS Min Age: 21Y None AGE 0-21 BILL CCS LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM 137MCG TABS Min Age: 21Y None AGE 0-21 BILL CCS

Page 79 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message LIDOCAINE HCL JELLY LIDOCAINE HYDROCHLORIDE 2% GEL None None 5 30

LIDOCAINE LIDOCAINE HYDROCHLORIDE 5% OINT None None 60 30

LIOTHYRONINE SODIUM LIOTHYRONINE SODIUM 25MCG TABS Min Age: 21Y None AGE 0-21 BILL CCS LIOTHYRONINE SODIUM LIOTHYRONINE SODIUM 5MCG TABS Min Age: 21Y None AGE 0-21 BILL CCS LIOTHYRONINE SODIUM LIOTHYRONINE SODIUM 50MCG TABS Min Age: 21Y None AGE 0-21 BILL CCS VICTOZA LIRAGLUTIDE 18MG/3ML SOPN Min Age: 21Y None PA required Call (888) 989-0091. For members age 0-21 BILL CCS. LISINOPRIL LISINOPRIL 5MG TABS Min Age: 21Y None AGE 0-21 BILL CCS LISINOPRIL LISINOPRIL 10MG TABS Min Age: 21Y None AGE 0-21 BILL CCS LISINOPRIL LISINOPRIL 20MG TABS Min Age: 21Y None AGE 0-21 BILL CCS LISINOPRIL LISINOPRIL 40MG TABS Min Age: 21Y None AGE 0-21 BILL CCS LISINOPRIL LISINOPRIL 2.5MG TABS Min Age: 21Y None AGE 0-21 BILL CCS LISINOPRIL LISINOPRIL 30MG TABS Min Age: 21Y None AGE 0-21 BILL CCS LORAZEPAM LORAZEPAM 0.5MG TABS None None 90 30 LORAZEPAM LORAZEPAM 1MG TABS None None 90 30 LORAZEPAM LORAZEPAM 2MG TABS None None 90 30 LOSARTAN POTASSIUM LOSARTAN POTASSIUM 25MG TABS Min Age: 21Y None 30 30 AGE 0-21 BILL CCS LOSARTAN POTASSIUM LOSARTAN POTASSIUM 50MG TABS Min Age: 21Y None 30 30 AGE 0-21 BILL CCS LOSARTAN POTASSIUM LOSARTAN POTASSIUM 100MG TABS Min Age: 21Y None 30 30 AGE 0-21 BILL CCS LOVASTATIN LOVASTATIN 20MG TABS Min Age: 21Y None AGE 0-21 BILL CCS LOVASTATIN LOVASTATIN 10MG TABS Min Age: 21Y None AGE 0-21 BILL CCS MAGNESIUM OXIDE MAGNESIUM OXIDE 400MG TABS None None 60 30 ASACOL HD MESALAMINE (5-ASA) 800MG TBEC Min Age: 21Y None 180 30 AGE 0-21 BILL CCS PENTASA MESALAMINE (5-ASA) 500MG CPCR Min Age: 21Y None 60 30 AGE 0-21 BILL CCS PENTASA MESALAMINE (5-ASA) 250MG CPCR Min Age: 21Y None 120 30 AGE 0-21 BILL CCS DELZICOL MESALAMINE (5-ASA) 400MG CPDR Min Age: 21Y None 180 30 AGE 0-21 BILL CCS MESALAMINE MESALAMINE (5-ASA) 4GM ENEM Min Age: 21Y None 1800 30 AGE 0-21 BILL CCS

Page 80 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message CANASA MESALAMINE (5-ASA) 1000MG SUPP Min Age: 21Y None 30 30 AGE 0-21 BILL CCS LIALDA MESALAMINE (5-ASA) 1.2GM TBEC Min Age: 21Y None 120 30 AGE 0-21 BILL CCS NORINYL 1+50 MESTRANOL; 50MCG; 1MG TABS None Female 30 30 NORETHINDRONE METFORMIN HCL METFORMIN HYDROCHLORIDE 500MG TABS None None 150 30

METFORMIN HCL METFORMIN HYDROCHLORIDE 850MG TABS None None 90 30

METFORMIN HCL METFORMIN HYDROCHLORIDE 1000MG TABS None None 90 30

METFORMIN HCL ER METFORMIN HYDROCHLORIDE 750MG TB24 None None 60 30

METFORMIN HCL ER METFORMIN HYDROCHLORIDE 500MG TB24 None None 120 30

METHAMPHETAMINE HCL METHAMPHETAMINE 5MG TABS Min Age: 21Y None PA Required HYDROCHLORIDE METHAZOLAMIDE METHAZOLAMIDE 50MG TABS Min Age: 21Y None AGE 0-21 BILL CCS METHAZOLAMIDE METHAZOLAMIDE 25MG TABS Min Age: 21Y None AGE 0-21 BILL CCS METHIMAZOLE METHIMAZOLE 10MG TABS Min Age: 21Y None AGE 0-21 BILL CCS METHIMAZOLE METHIMAZOLE 5MG TABS Min Age: 21Y None AGE 0-21 BILL CCS METHYLERGONOVINE MALEATE METHYLERGONOVINE 0.2MG TABS None None 30 30 MALEATE METHYLPHENIDATE HCL METHYLPHENIDATE 10MG TABS Min Age: 5Y None 90 30 HYDROCHLORIDE Max Age: 18Y METHYLPHENIDATE HCL METHYLPHENIDATE 5MG TABS Min Age: 5Y None 90 30 HYDROCHLORIDE Max Age: 18Y METHYLPHENIDATE HCL METHYLPHENIDATE 20MG TABS Min Age: 5Y None 90 30 HYDROCHLORIDE Max Age: 18Y METHYLPHENIDATE HCL SR METHYLPHENIDATE 20MG TBCR Min Age: 5Y None 90 30 HYDROCHLORIDE Max Age: 18Y METHYLPHENIDATE HCL ER METHYLPHENIDATE 10MG TBCR Min Age: 5Y None 60 30 HYDROCHLORIDE Max Age: 18Y METOLAZONE METOLAZONE 10MG TABS Min Age: 21Y None AGE 0-21 BILL CCS METOLAZONE METOLAZONE 2.5MG TABS Min Age: 21Y None AGE 0-21 BILL CCS METOLAZONE METOLAZONE 5MG TABS Min Age: 21Y None AGE 0-21 BILL CCS METOPROLOL SUCCINATE ER METOPROLOL SUCCINATE 25MG TB24 Min Age: 21Y None AGE 0-21 BILL CCS METOPROLOL SUCCINATE ER METOPROLOL SUCCINATE 50MG TB24 Min Age: 21Y None AGE 0-21 BILL CCS METOPROLOL SUCCINATE ER METOPROLOL SUCCINATE 100MG TB24 Min Age: 21Y None AGE 0-21 BILL CCS

Page 81 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message METOPROLOL SUCCINATE ER METOPROLOL SUCCINATE 200MG TB24 Min Age: 21Y None AGE 0-21 BILL CCS METOPROLOL TARTRATE METOPROLOL TARTRATE 25MG TABS Min Age: 21Y None AGE 0-21 BILL CCS METOPROLOL TARTRATE METOPROLOL TARTRATE 100MG TABS Min Age: 21Y None AGE 0-21 BILL CCS METOPROLOL TARTRATE METOPROLOL TARTRATE 50MG TABS Min Age: 21Y None AGE 0-21 BILL CCS METRONIDAZOLE METRONIDAZOLE 1% GEL None None 60 30 Use metronidazole 0.75% gel METRONIDAZOLE METRONIDAZOLE 1% GEL None None 60 30 Use metronidazole 0.75% gel METRONIDAZOLE METRONIDAZOLE 0.75% LOTN None None 59 30 METRONIDAZOLE METRONIDAZOLE 0.75% GEL None None 45 30 METRONIDAZOLE METRONIDAZOLE 0.75% CREA None None 45 30 MEXILETINE HCL MEXILETINE HYDROCHLORIDE 150MG CAPS Min Age: 21Y None AGE 0-21 BILL CCS MEXILETINE HCL MEXILETINE HYDROCHLORIDE 200MG CAPS Min Age: 21Y None AGE 0-21 BILL CCS MEXILETINE HCL MEXILETINE HYDROCHLORIDE 250MG CAPS Min Age: 21Y None AGE 0-21 BILL CCS MINOCYCLINE HCL MINOCYCLINE 100MG CAPS None None 60 30 HYDROCHLORIDE MINOCYCLINE HCL MINOCYCLINE 50MG CAPS None None 60 30 HYDROCHLORIDE MOEXIPRIL HCL MOEXIPRIL HYDROCHLORIDE 7.5MG TABS Min Age: 21Y None AGE 0-21 BILL CCS MOEXIPRIL HCL MOEXIPRIL HYDROCHLORIDE 15MG TABS Min Age: 21Y None AGE 0-21 BILL CCS ASMANEX TWISTHALER 120 MOMETASONE FUROATE 220MCG/INH AEPB None None 2 30 METERED DOSES ASMANEX TWISTHALER 14 MOMETASONE FUROATE 220MCG/INH AEPB None None 2 30 METERED DOSES ASMANEX TWISTHALER 30 ME MOMETASONE FUROATE 220MCG/INH AEPB None None 2 30 TERED DOSES ASMANEX TWISTHALER 60 MOMETASONE FUROATE 220MCG/INH AEPB None None 2 30 METERED DOSES ASMANEX TWISTHALER 30 MOMETASONE FUROATE 110MCG/INH AEPB None None 2 30 METERED DOSES ASMANEX TWISTHALER 7 MOMETASONE FUROATE 110MCG/INH AEPB None None 2 30 METERED DOSES MOMETASONE FUROATE MOMETASONE FUROATE 0.1% SOLN None None 240 30 MOMETASONE FUROATE MOMETASONE FUROATE 0.1% CREA None None 60 30 MOMETASONE FUROATE MOMETASONE FUROATE 0.1% OINT None None 60 30 MONTELUKAST SODIUM MONTELUKAST SODIUM 4MG PACK None None 30 30 MONTELUKAST SODIUM MONTELUKAST SODIUM 4MG CHEW None None 30 30 MONTELUKAST SODIUM MONTELUKAST SODIUM 5MG CHEW None None 30 30 MONTELUKAST SODIUM MONTELUKAST SODIUM 10MG TABS None None 30 30

Page 82 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message MORPHINE SULFATE MORPHINE SULFATE 15MG TABS None None 120 30 MORPHINE SULFATE MORPHINE SULFATE 30MG TABS None None 120 30 MYCOPHENOLATE MOFETIL MYCOPHENOLATE MOFETIL 250MG CAPS Min Age: 21Y None 180 30 AGE 0-21 BILL CCS MYCOPHENOLATE MOFETIL MYCOPHENOLATE MOFETIL 500MG TABS Min Age: 21Y None 180 30 AGE 0-21 BILL CCS NADOLOL NADOLOL 40MG TABS Min Age: 21Y None AGE 0-21 BILL CCS NADOLOL NADOLOL 80MG TABS Min Age: 21Y None AGE 0-21 BILL CCS NADOLOL NADOLOL 20MG TABS Min Age: 21Y None AGE 0-21 BILL CCS NEFAZODONE HCL NEFAZODONE 50MG TABS None None 60 30 HYDROCHLORIDE NEFAZODONE HCL NEFAZODONE 100MG TABS None None 60 30 HYDROCHLORIDE NEFAZODONE HCL NEFAZODONE 150MG TABS None None 120 30 HYDROCHLORIDE NEFAZODONE HCL NEFAZODONE 200MG TABS None None 60 30 HYDROCHLORIDE NEFAZODONE HCL NEFAZODONE 250MG TABS None None 60 30 HYDROCHLORIDE NIACIN TR NIACIN 500MG TBCR None None 120 30 NICOTINE NICOTINE 7MG/24HR PT24 None None 30 30 Member allowed 6 fills per year

NICOTINE NICOTINE 14MG/24HR PT24 None None 30 30 Member allowed 6 fills per year

NICOTINE NICOTINE 21MG/24HR PT24 None None 30 30 Member allowed 6 fills per year

NICOTINE POLACRILEX NICOTINE POLACRILEX 2MG GUM None None 360 30 Member allowed 6 fills per year

NICOTINE POLACRILEX NICOTINE POLACRILEX 4MG GUM None None 360 30 Member allowed 6 fills per year

NIFEDIPINE ER NIFEDIPINE 30MG TB24 Min Age: 21Y None 30 30 AGE 0-21 BILL CCS NIFEDIPINE ER NIFEDIPINE 60MG TB24 Min Age: 21Y None 60 30 AGE 0-21 BILL CCS NIFEDIPINE ER NIFEDIPINE 90MG TB24 Min Age: 21Y None 60 30 AGE 0-21 BILL CCS NIFEDIPINE ER NIFEDIPINE 30MG TB24 Min Age: 21Y None 30 30 AGE 0-21 BILL CCS NIFEDIPINE ER NIFEDIPINE 60MG TB24 Min Age: 21Y None 60 30 AGE 0-21 BILL CCS NIFEDIPINE ER NIFEDIPINE 90MG TB24 Min Age: 21Y None 30 30 AGE 0-21 BILL CCS

Page 83 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message NIFEDIPINE NIFEDIPINE 10MG CAPS Min Age: 21Y None 120 30 AGE 0-21 BILL CCA NITRO-BID NITROGLYCERIN 2% OINT Min Age: 21Y None AGE 0-21 BILL CCS NITROSTAT NITROGLYCERIN 0.3MG SUBL Min Age: 21Y None AGE 0-21 BILL CCS NITROSTAT NITROGLYCERIN 0.4MG SUBL Min Age: 21Y None AGE 0-21 BILL CCS NITROSTAT NITROGLYCERIN 0.6MG SUBL Min Age: 21Y None AGE 0-21 BILL CCS NORA-BE NORETHINDRONE 0.35MG TABS None Female 30 30

NYSTATIN NYSTATIN 100000UNIT/GM CREA None None 120 30 NYSTATIN NYSTATIN 100000UNIT/GM OINT None None 120 30 NYSTATIN NYSTATIN 100000UNIT/GM POWD None None 1280 30 NYSTATIN/TRIAMCINOLONE NYSTATIN; TRIAMCINOLONE 100000UNIT/GM; 0.1% CREA None None 480 30 ACETONIDE

NYSTATIN/TRIAMCINOLONE NYSTATIN; TRIAMCINOLONE 100000UNIT/GM; 0.1% OINT None None 480 30 ACETONIDE

OFLOXACIN OFLOXACIN 0.3% SOLN None None 1 365 Member allowed 1 fill per year

OMEPRAZOLE OMEPRAZOLE 20MG CPDR None None 60 30 FIRST-OMEPRAZOLE OMEPRAZOLE 2MG/ML SUSP Max Age: 12Y None 300 30 For members >12y/o use omeperazole caps or pantoprazole tabs OMEPRAZOLE OMEPRAZOLE 40MG CPDR None None 60 30 ONDANSETRON ODT ONDANSETRON 4MG TBDP None None 60 30 ONDANSETRON ODT ONDANSETRON 8MG TBDP None None 60 30 ONDANSETRON HCL ONDANSETRON HCL 4MG TABS None None 60 30 ONDANSETRON HCL ONDANSETRON HCL 8MG TABS None None 60 30 TAMIFLU OSELTAMIVIR PHOSPHATE 6MG/ML SUSR Max Age: 12Y None 120 30 Member allowed 1 fill per 180 days TAMIFLU OSELTAMIVIR PHOSPHATE 75MG CAPS None None 1 180 Member allowed 1 fill per 180 days TAMIFLU OSELTAMIVIR PHOSPHATE 30MG CAPS Max Age: 12Y None 20 10 Member allowed 1 fill per 180 days TAMIFLU OSELTAMIVIR PHOSPHATE 45MG CAPS Max Age: 12Y None 10 10 Member allowed 1 fill per 180 days OXCARBAZEPINE 300MG TABS None None 60 30 OXCARBAZEPINE OXCARBAZEPINE 600MG TABS None None 120 30

Page 84 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message OXCARBAZEPINE OXCARBAZEPINE 300MG/5ML SUSP Max Age: 12Y None 1200 30 OXCARBAZEPINE OXCARBAZEPINE 150MG TABS None None 60 30 OXYBUTYNIN CHLORIDE ER OXYBUTYNIN CHLORIDE 5MG TB24 None None 30 30 Use oxybutynin IR OXYBUTYNIN CHLORIDE ER OXYBUTYNIN CHLORIDE 10MG TB24 None None 60 30 Use oxybutynin IR OXYBUTYNIN CHLORIDE ER OXYBUTYNIN CHLORIDE 15MG TB24 None None 60 30 Use oxybutynin IR OXYCODONE HCL OXYCODONE 5MG TABS None None 120 30 HYDROCHLORIDE OXYCODONE HCL OXYCODONE 10MG TABS None None 120 30 HYDROCHLORIDE OXYCODONE HCL OXYCODONE 15MG TABS None None 120 30 HYDROCHLORIDE OXYCODONE HCL OXYCODONE 30MG TABS None None 120 30 HYDROCHLORIDE OXYCODONE HCL OXYCODONE 20MG TABS None None 120 30 HYDROCHLORIDE OXYMORPHONE OXYMORPHONE 10MG TABS None None 120 30 PA Required HYDROCHLORIDE HYDROCHLORIDE OXYMORPHONE OXYMORPHONE 5MG TB12 None None 120 30 Use methadone HYDROCHLORIDE ER HYDROCHLORIDE or morphine

OXYMORPHONE OXYMORPHONE 10MG TB12 None None 120 30 Use methadone HYDROCHLORIDE ER HYDROCHLORIDE or morphine

OXYMORPHONE OXYMORPHONE 20MG TB12 None None 120 30 Use methadone HYDROCHLORIDE ER HYDROCHLORIDE or morphine

OXYMORPHONE OXYMORPHONE 7.5MG TB12 None None 120 30 Use methadone HYDROCHLORIDE ER HYDROCHLORIDE or morphine

OXYMORPHONE OXYMORPHONE 15MG TB12 None None 120 30 PA Required HYDROCHLORIDE ER HYDROCHLORIDE PANTOPRAZOLE SODIUM PANTOPRAZOLE SODIUM 40MG TBEC None None 60 30 SESQUIHYDRATE PANTOPRAZOLE SODIUM PANTOPRAZOLE SODIUM 20MG TBEC None None 60 30 SESQUIHYDRATE PENTOXIFYLLINE ER PENTOXIFYLLINE 400MG TBCR None None 90 30 PERINDOPRIL ERBUMINE PERINDOPRIL ERBUMINE 2MG TABS Min Age: 21Y None AGE 0-21 BILL CCS PERINDOPRIL ERBUMINE PERINDOPRIL ERBUMINE 4MG TABS Min Age: 21Y None AGE 0-21 BILL CCS PERINDOPRIL ERBUMINE PERINDOPRIL ERBUMINE 8MG TABS Min Age: 21Y None AGE 0-21 BILL CCS PERMETHRIN PERMETHRIN 5% CREA None None 60 30 DIBENZYLINE PHENOXYBENZAMINE 10MG CAPS Min Age: 21Y None AGE 0-21 BILL HYDROCHLORIDE CCS PHENYTOIN PHENYTOIN 50MG CHEW None None 180 30 PHENYTOIN PHENYTOIN 125MG/5ML SUSP Max Age: 12Y None 450 30 PA Required

Page 85 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message PHENYTOIN SODIUM EXTENDED PHENYTOIN SODIUM 300MG CAPS None None 180 30

PHENYTOIN SODIUM EXTENDED PHENYTOIN SODIUM 200MG CAPS None None 180 30

PHENYTOIN SODIUM EXTENDED PHENYTOIN SODIUM 100MG CAPS None None 180 30

DILANTIN PHENYTOIN SODIUM 30MG CAPS None None 180 30 PILOCARPINE HYDROCHLORIDE PILOCARPINE 5MG TABS None None 180 30 HYDROCHLORIDE ELIDEL PIMECROLIMUS 1% CREA Min Age: 2Y None 30 30 Use 2 medium to high potency steroid PINDOLOL PINDOLOL 10MG TABS None None 60 30 PINDOLOL PINDOLOL 5MG TABS None None 60 30 PIOGLITAZONE HCL PIOGLITAZONE 15MG TABS None None 30 30 HYDROCHLORIDE PIOGLITAZONE HCL PIOGLITAZONE 30MG TABS None None 30 30 HYDROCHLORIDE PIOGLITAZONE HCL PIOGLITAZONE 45MG TABS None None 30 30 HYDROCHLORIDE POLYETHYLENE GLYCOL 3350 POLYETHYLENE GLYCOL 0 PACK None None 527 30 POLYETHYLENE GLYCOL 3350 POLYETHYLENE GLYCOL 0 POWD None None 527 30 POTASSIUM CITRATE ER POTASSIUM CITRATE 540MG TBCR None None 120 30 POTASSIUM CITRATE ER POTASSIUM CITRATE 1080MG TBCR None None 120 30 POTASSIUM CITRATE ER POTASSIUM CITRATE 15MEQ TBCR None None 120 30 EFFIENT PRASUGREL HYDROCHLORIDE 5MG TABS None None 30 30 Use clopidogrel

EFFIENT PRASUGREL HYDROCHLORIDE 10MG TABS None None 30 30 Use clopidogrel

PRAVASTATIN SODIUM PRAVASTATIN SODIUM 10MG TABS Min Age: 21Y None 30 30 AGE 0-21 BILL CCS PRAVASTATIN SODIUM PRAVASTATIN SODIUM 20MG TABS Min Age: 21Y None 30 30 AGE 0-21 BILL CCS PRAVASTATIN SODIUM PRAVASTATIN SODIUM 40MG TABS Min Age: 21Y None 60 30 AGE 0-21 BILL CCS PRAVASTATIN SODIUM PRAVASTATIN SODIUM 80MG TABS Min Age: 21Y None AGE 0-21 BILL CCS PRIMIDONE PRIMIDONE 250MG TABS None None 240 30 PRIMIDONE PRIMIDONE 50MG TABS None None 240 30 PROBENECID PROBENECID 500MG TABS None None 120 30 PROGESTERONE PROGESTERONE 100MG CAPS None None 30 30 PROGESTERONE PROGESTERONE 200MG CAPS None None 30 30 PROMETHAZINE HCL PROMETHAZINE 25MG/ML SOLN Min Age: 2Y None HYDROCHLORIDE PROMETHAZINE HCL PROMETHAZINE 50MG/ML SOLN Min Age: 2Y None HYDROCHLORIDE PROMETHAZINE HCL PROMETHAZINE 25MG SUPP Min Age: 2Y None HYDROCHLORIDE PROMETHEGAN PROMETHAZINE 50MG SUPP Min Age: 2Y None PA Required HYDROCHLORIDE

Page 86 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message PHENADOZ PROMETHAZINE 12.5MG SUPP Min Age: 2Y None HYDROCHLORIDE PROMETHAZINE HCL PROMETHAZINE 6.25MG/5ML SOLN Min Age: 2Y None HYDROCHLORIDE PROMETHAZINE HCL PROMETHAZINE 12.5MG TABS Min Age: 2Y None HYDROCHLORIDE PROMETHAZINE HCL PROMETHAZINE 25MG TABS Min Age: 2Y None HYDROCHLORIDE PROMETHAZINE HCL PROMETHAZINE 50MG TABS Min Age: 2Y None HYDROCHLORIDE PROPAFENONE HCL PROPAFENONE HCL 150MG TABS Min Age: 21Y None AGE 0-21 BILL CCS PROPAFENONE HCL PROPAFENONE HCL 300MG TABS Min Age: 21Y None AGE 0-21 BILL CCS PROPAFENONE HCL PROPAFENONE HCL 225MG TABS Min Age: 21Y None AGE 0-21 BILL CCS PROPRANOLOL HCL ER PROPRANOLOL 80MG CP24 Min Age: 21Y None 30 30 AGE 0-21 BILL HYDROCHLORIDE CCS PROPRANOLOL HCL ER PROPRANOLOL 120MG CP24 Min Age: 21Y None 60 30 AGE 0-21 BILL HYDROCHLORIDE CCS PROPRANOLOL HCL ER PROPRANOLOL 160MG CP24 Min Age: 21Y None 60 30 AGE 0-21 BILL HYDROCHLORIDE CCS PROPRANOLOL HCL ER PROPRANOLOL 60MG CP24 Min Age: 21Y None 30 30 AGE 0-21 BILL HYDROCHLORIDE CCS PROPRANOLOL HCL PROPRANOLOL 10MG TABS Min Age: 21Y None AGE 0-21 BILL HYDROCHLORIDE CCS PROPRANOLOL HCL PROPRANOLOL 20MG TABS Min Age: 21Y None AGE 0-21 BILL HYDROCHLORIDE CCS PROPRANOLOL HCL PROPRANOLOL 40MG TABS Min Age: 21Y None AGE 0-21 BILL HYDROCHLORIDE CCS PROPRANOLOL HCL PROPRANOLOL 60MG TABS Min Age: 21Y None AGE 0-21 BILL HYDROCHLORIDE CCS PROPRANOLOL HCL PROPRANOLOL 80MG TABS Min Age: 21Y None AGE 0-21 BILL HYDROCHLORIDE CCS PROPRANOLOL HCL PROPRANOLOL 20MG/5ML SOLN Min Age: 21Y None AGE 0-21 BILL HYDROCHLORIDE CCS PROPRANOLOL HCL PROPRANOLOL 40MG/5ML SOLN Min Age: 21Y None AGE 0-21 BILL HYDROCHLORIDE CCS PROPYLTHIOURACIL PROPYLTHIOURACIL 50MG TABS Min Age: 21Y None AGE 0-21 BILL CCS QUINAPRIL HCL QUINAPRIL HCL 10MG TABS Min Age: 21Y None AGE 0-21 BILL CCS QUINAPRIL HCL QUINAPRIL HCL 20MG TABS Min Age: 21Y None AGE 0-21 BILL CCS QUINAPRIL HCL QUINAPRIL HCL 5MG TABS Min Age: 21Y None AGE 0-21 BILL CCS QUINAPRIL HCL QUINAPRIL HCL 40MG TABS Min Age: 21Y None AGE 0-21 BILL CCS RALOXIFENE HYDROCHLORIDE RALOXIFENE 60MG TABS Min Age: 21Y Female HYDROCHLORIDE

Page 87 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message RAMIPRIL RAMIPRIL 1.25MG CAPS Min Age: 21Y None AGE 0-21 BILL CCS RAMIPRIL RAMIPRIL 2.5MG CAPS Min Age: 21Y None AGE 0-21 BILL CCS RAMIPRIL RAMIPRIL 5MG CAPS Min Age: 21Y None AGE 0-21 BILL CCS RAMIPRIL RAMIPRIL 10MG CAPS Min Age: 21Y None AGE 0-21 BILL CCS RESERPINE RESERPINE 0.1MG TABS Min Age: 21Y None PA REquierd however for members age 0- 21 BILL CCS RESERPINE RESERPINE 0.25MG TABS Min Age: 21Y None PA REquierd however for members age 0- 21 BILL CCS XIFAXAN RIFAXIMIN 550MG TABS None None 60 30 Use Lactulose XIFAXAN RIFAXIMIN 200MG TABS None None 90 30 Use Lactulose RIZATRIPTAN BENZOATE RIZATRIPTAN BENZOATE 5MG TABS Min Age: 6Y None 9 30 Medication will pay at POS for Max Age: members 6-18 18Y years old. For all other members, step therapy with sumatriptan is required RIZATRIPTAN BENZOATE RIZATRIPTAN BENZOATE 10MG TABS Min Age: 6Y None 9 30 Medication will pay at POS for Max Age: members 6-18 18Y years old. For all other members, step therapy with sumatriptan is required ROPINIROLE HCL ROPINIROLE 0.25MG TABS None None 120 30 HYDROCHLORIDE ROPINIROLE HCL ROPINIROLE 1MG TABS None None 120 30 HYDROCHLORIDE ROPINIROLE HCL ROPINIROLE 2MG TABS None None 60 30 HYDROCHLORIDE ROPINIROLE HCL ROPINIROLE 5MG TABS None None 30 30 HYDROCHLORIDE ROPINIROLE HCL ROPINIROLE 0.5MG TABS None None 120 30 HYDROCHLORIDE ROPINIROLE HCL ROPINIROLE 4MG TABS None None 30 30 HYDROCHLORIDE ROPINIROLE HCL ROPINIROLE 3MG TABS None None 60 30 HYDROCHLORIDE

Page 88 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message CRESTOR ROSUVASTATIN CALCIUM 10MG TABS Min Age: 21Y None Use atorvastatin. PA Required call (888) 989-0091. For members age 0-21 BILL CCS

CRESTOR ROSUVASTATIN CALCIUM 20MG TABS Min Age: 21Y None Use atorvastatin. PA Required call (888) 989-0091. For members age 0-21 BILL CCS

CRESTOR ROSUVASTATIN CALCIUM 40MG TABS Min Age: 21Y None Use atorvastatin. PA Required call (888) 989-0091. For members age 0-21 BILL CCS

CRESTOR ROSUVASTATIN CALCIUM 5MG TABS Min Age: 21Y None Use atorvastatin. PA Required call (888) 989-0091. For members age 0-21 BILL CCS

SALICYLIC ACID SALICYLIC ACID 17% SOLN None None 15 30 RA WART REMOVER SALICYLIC ACID 17% SOLN None None 14.8 30 SERTRALINE HCL SERTRALINE 25MG TABS None None 45 30 HYDROCHLORIDE SERTRALINE HCL SERTRALINE 50MG TABS None None 45 30 HYDROCHLORIDE SERTRALINE HCL SERTRALINE 100MG TABS None None 60 30 HYDROCHLORIDE SIMVASTATIN SIMVASTATIN 5MG TABS Min Age: 21Y None 30 30 AGE 0-21 BILL CCS SIMVASTATIN SIMVASTATIN 10MG TABS Min Age: 21Y None 30 30 AGE 0-21 BILL CCS SIMVASTATIN SIMVASTATIN 20MG TABS Min Age: 21Y None 30 30 AGE 0-21 BILL CCS SIMVASTATIN SIMVASTATIN - HIGH DOSE 40MG TABS Min Age: 21Y None 30 30 AGE 0-21 BILL (40 MG & HIGHER) CCS SIMVASTATIN SIMVASTATIN - HIGH DOSE 80MG TABS Min Age: 21Y None 30 30 AGE 0-21 BILL (40 MG & HIGHER) CCS DEEP SEA NASAL SPRAY SODIUM CHLORIDE 0.65% SOLN None None 90 30 SODIUM POLYSTYRENE SODIUM POLYSTYRENE 15GM/60ML SUSP None None 240 30 SULFONATE SULFONATE SOTALOL HCL SOTALOL HYDROCHLORIDE 80MG TABS Min Age: 21Y None 120 30 AGE 0-21 BILL CCA

Page 89 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message SOTALOL HCL SOTALOL HYDROCHLORIDE 120MG TABS Min Age: 21Y None 60 30 AGE 0-21 BILL CCS SPIRONOLACTONE SPIRONOLACTONE 100MG TABS Min Age: 21Y None AGE 0-21 BILL CCS SPIRONOLACTONE SPIRONOLACTONE 25MG TABS Min Age: 21Y None AGE 0-21 BILL CCS SPIRONOLACTONE SPIRONOLACTONE 50MG TABS Min Age: 21Y None AGE 0-21 BILL CCS CARAFATE SUCRALFATE 1GM/10ML SUSP Max Age: 12Y None SUMATRIPTAN SUCCINATE SUMATRIPTAN SUCCINATE 50MG TABS Min Age: 12Y None 9 30 SUMATRIPTAN SUCCINATE SUMATRIPTAN SUCCINATE 100MG TABS Min Age: 12Y None 9 30 SUMATRIPTAN SUCCINATE SUMATRIPTAN SUCCINATE 25MG TABS Min Age: 12Y None 9 30 TACROLIMUS TACROLIMUS 1MG CAPS Min Age: 21Y None 270 30 AGE 0-21 BILL CCS TACROLIMUS TACROLIMUS 5MG CAPS Min Age: 21Y None 120 30 AGE 0-21 BILL CCS HECORIA TACROLIMUS 0.5MG CAPS Min Age: 21Y None 120 30 AGE 0-21 BILL CCS TAMSULOSIN HCL TAMSULOSIN 0.4MG CAPS None None 60 30 HYDROCHLORIDE TELMISARTAN TELMISARTAN 40MG TABS Min Age: 21Y None PA required Call (888) 989-0091. For members age 0-21 BILL CCS TELMISARTAN TELMISARTAN 80MG TABS Min Age: 21Y None PA required Call (888) 989-0091. For members age 0-21 BILL CCS TELMISARTAN TELMISARTAN 20MG TABS Min Age: 21Y None PA required Call (888) 989-0091. For members age 0-21 BILL CCS TEMAZEPAM TEMAZEPAM 15MG CAPS None None 30 30 TEMAZEPAM TEMAZEPAM 30MG CAPS None None 30 30 TEMAZEPAM TEMAZEPAM 7.5MG CAPS None None 30 30 TEMAZEPAM TEMAZEPAM 22.5MG CAPS None None 30 30 TERAZOSIN HCL TERAZOSIN HCL 1MG CAPS None None 90 30 TERAZOSIN HCL TERAZOSIN HCL 2MG CAPS None None 120 30 TERAZOSIN HCL TERAZOSIN HCL 5MG CAPS None None 90 30 TERAZOSIN HCL TERAZOSIN HCL 10MG CAPS None None 60 30 TERBINAFINE HCL TERBINAFINE 250MG TABS None None 90 365 HYDROCHLORIDE TERBINAFINE HCL TERBINAFINE 1% CREA None None 120 30 Member allowed HYDROCHLORIDE 2 fills per year

TETRACYCLINE HCL TETRACYCLINE 250MG CAPS None None 120 30 HYDROCHLORIDE

Page 90 of 94 San Francisco Health Plan Medi-Cal Formulary Restrictions AS OF OCTOBER 2014

Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message TETRACYCLINE HCL TETRACYCLINE 500MG CAPS None None 120 30 HYDROCHLORIDE ARMOUR THYROID THYROID 15MG TABS Min Age: 21Y None AGE 0-21 BILL CCS NP THYROID 30 THYROID 30MG TABS Min Age: 21Y None AGE 0-21 BILL CCS NP THYROID 60 THYROID 60MG TABS Min Age: 21Y None AGE 0-21 BILL CCS NP THYROID 90 THYROID 90MG TABS Min Age: 21Y None AGE 0-21 BILL CCS ARMOUR THYROID THYROID 120MG TABS Min Age: 21Y None AGE 0-21 BILL CCS ARMOUR THYROID THYROID 180MG TABS Min Age: 21Y None AGE 0-21 BILL CCS ARMOUR THYROID THYROID 300MG TABS Min Age: 21Y None AGE 0-21 BILL CCS LACTASE TILACTASE (LACTASE) 3000UNIT TABS Min Age: 21Y None AGE 0-21 BILL CCS LACTOSE FAST ACTING RELIEF TILACTASE (LACTASE) 9000UNIT TABS Min Age: 21Y None AGE 0-21 BILL CCS SPIRIVA HANDIHALER TIOTROPIUM BROMIDE 18MCG CAPS None None 30 30 MONOHYDRATE TIZANIDINE HCL TIZANIDINE HYDROCHLORIDE 2MG TABS None None 90 30

TIZANIDINE HCL TIZANIDINE HYDROCHLORIDE 4MG TABS None None 90 30

TOLNAFTATE TOLNAFTATE 1% CREA None None 120 30 TOPIRAMATE TOPIRAMATE 50MG TABS None None 60 30 TOPIRAMATE TOPIRAMATE 100MG TABS None None 60 30 TOPIRAMATE TOPIRAMATE 200MG TABS None None 120 30 TOPIRAMATE TOPIRAMATE 25MG TABS None None 60 30 TOPIRAMATE TOPIRAMATE 15MG CPSP None None 60 30 TOPIRAMATE TOPIRAMATE 25MG CPSP None None 120 30 TRAMADOL HCL TRAMADOL HCL 50MG TABS None None 240 30 Max dose 8 tabs/day TRANDOLAPRIL TRANDOLAPRIL 1MG TABS Min Age: 21Y None PA required Call (888)989-0091. For members age 0-21 BILL CCS TRANDOLAPRIL TRANDOLAPRIL 2MG TABS Min Age: 21Y None PA required Call (888)989-0091. For members age 0-21 BILL CCS TRANDOLAPRIL TRANDOLAPRIL 4MG TABS Min Age: 21Y None PA required Call (888)989-0091. For members age 0-21 BILL CCS

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Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message TRAVOPROST TRAVOPROST 0.004% SOLN Min Age: 21Y None 2.5 25 Use latanoprost. AGE 0-21 BILL CCS

TRETINOIN TRETINOIN 0.01% GEL Max Age: 30Y None 15 30 Max #15 per 30 days TRETINOIN TRETINOIN 0.025% GEL Max Age: 30Y None 15 30 Max #15 per 30 days TRETINOIN TRETINOIN 0.05% CREA Max Age: 30Y None 20 30 Max #20 per 30 days TRETINOIN TRETINOIN 0.1% CREA Max Age: 30Y None 20 30 Max #20 per 30 days TRETINOIN TRETINOIN 0.025% CREA Max Age: 30Y None 20 30 Max #20 per 30 days NASACORT ALLERGY 24HR TRIAMCINOLONE ACETONIDE 55MCG/ACT AERO None None 16.9 30

TRIAMCINOLONE ACETONIDE TRIAMCINOLONE ACETONIDE 0.025% CREA None None 240 30

TRIAMCINOLONE ACETONIDE TRIAMCINOLONE ACETONIDE 0.1% CREA None None 454 30

TRIAMCINOLONE ACETONIDE TRIAMCINOLONE ACETONIDE 0.5% CREA None None 240 30

TRIAMCINOLONE ACETONIDE TRIAMCINOLONE ACETONIDE 0.025% OINT None None 240 30

TRIAMCINOLONE ACETONIDE TRIAMCINOLONE ACETONIDE 0.1% OINT None None 240 30

TRIANEX TRIAMCINOLONE ACETONIDE 0.05% OINT None None 240 30

TRIAMCINOLONE ACETONIDE TRIAMCINOLONE ACETONIDE 0.5% OINT None None 240 30

TRIAMCINOLONE ACETONIDE TRIAMCINOLONE ACETONIDE 0.025% LOTN None None 240 30

TRIAMCINOLONE ACETONIDE TRIAMCINOLONE ACETONIDE 0.1% LOTN None None 240 30

ELLA ULIPRISTAL ACETATE 30MG TABS None Female 1 30 Member is allowed 6 fills per year UREA UREA (CARBAMIDE) 20% CREA None None 85 30 Quantity limit #85 per 30 days OR PA required

VALACYCLOVIR HCL VALACYCLOVIR HCL 500MG TABS None None 90 30 Use acyclovir VALACYCLOVIR HCL VALACYCLOVIR HCL 1000MG TABS None None 90 30 Use acyclovir VALPROIC ACID SODIUM 250MG/5ML SYRP Max Age: 12Y None 840 30

VALPROIC ACID VALPROIC ACID 250MG CAPS None None 120 30

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Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message VALSARTAN VALSARTAN 320MG TABS Min Age: 21Y None Use ACEIs or losartan. PA required Call (888) 989-0091. For members age 0-21 BILL CCS. VALSARTAN VALSARTAN 160MG TABS None Use ACEIs or losartan. PA required Call (888) 989-0091. For members age 0-21 BILL CCS. VALSARTAN VALSARTAN 80MG TABS None Use ACEIs or losartan. PA required Call (888) 989-0091. For members age 0-21 BILL CCS. VALSARTAN VALSARTAN 40MG TABS None Use ACEIs or losartan. PA required Call (888) 989-0091. For members age 0-21 BILL CCS. VANCOMYCIN HCL VANCOMYCIN 125MG CAPS None None 40 10 Use HYDROCHLORIDE metronidazole VANCOMYCIN HCL VANCOMYCIN 250MG CAPS None None 40 10 Use HYDROCHLORIDE metronidazole CHANTIX VARENICLINE TARTRATE 0.5MG TABS None None 60 30 Member allowed 6 fills per year

CHANTIX VARENICLINE TARTRATE 1MG TABS None None 60 30 Member allowed 6 fills per year

CHANTIX STARTING MONTH VARENICLINE TARTRATE 0 TABS None None 53 30 Member allowed PAK 3 fills per year

VENLAFAXINE HCL VENLAFAXINE HCL 25MG TABS None None 60 30 VENLAFAXINE HCL VENLAFAXINE HCL 37.5MG TABS None None 60 30 VENLAFAXINE HCL VENLAFAXINE HCL 50MG TABS None None 60 30 VENLAFAXINE HCL VENLAFAXINE HCL 75MG TABS None None 60 30 VENLAFAXINE HCL VENLAFAXINE HCL 100MG TABS None None 60 30 VENLAFAXINE HCL ER VENLAFAXINE HCL 37.5MG CP24 None None 30 30 VENLAFAXINE HCL ER VENLAFAXINE HCL 75MG CP24 None None 90 30 VENLAFAXINE HCL ER VENLAFAXINE HCL 150MG CP24 None None 60 30 VERAPAMIL HCL VERAPAMIL HYDROCHLORIDE 80MG TABS Min Age: 21Y None AGE 0-21 BILL CCS

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Trade Name Ingredient Dosage Dosage Form Age Limit Gender Limit Quantity Max Quantity Days Coverage Message VERAPAMIL HCL ER VERAPAMIL HYDROCHLORIDE 180MG CP24 Min Age: 21Y None AGE 0-21 BILL CCS VERAPAMIL HCL ER VERAPAMIL HYDROCHLORIDE 240MG CP24 Min Age: 21Y None AGE 0-21 BILL CCS VERAPAMIL HCL ER VERAPAMIL HYDROCHLORIDE 120MG CP24 Min Age: 21Y None AGE 0-21 BILL CCS VERAPAMIL HCL SR VERAPAMIL HYDROCHLORIDE 360MG CP24 Min Age: 21Y None AGE 0-21 BILL CCS VERAPAMIL HCL ER VERAPAMIL HYDROCHLORIDE 240MG TBCR Min Age: 21Y None AGE 0-21 BILL CCS VERAPAMIL HCL ER VERAPAMIL HYDROCHLORIDE 180MG TBCR Min Age: 21Y None AGE 0-21 BILL CCS VERAPAMIL HCL ER VERAPAMIL HYDROCHLORIDE 120MG TBCR Min Age: 21Y None AGE 0-21 BILL CCS RELENZA DISKHALER ZANAMIVIR 5MG/BLISTER AEPB None None 20 30 Member allowed 1 fill per year

ZIDOVUDINE ZIDOVUDINE 50MG/5ML SYRP Min Age: 21Y None AGE 0-21 BILL CCS ZIDOVUDINE ZIDOVUDINE 100MG CAPS Min Age: 21Y None AGE 0-21 BILL CCS ZIDOVUDINE ZIDOVUDINE 300MG TABS Min Age: 21Y None AGE 0-21 BILL CCS ZOLPIDEM TARTRATE ZOLPIDEM TARTRATE 5MG TABS Min Age: 18Y None 30 30 ZOLPIDEM TARTRATE ZOLPIDEM TARTRATE 10MG TABS Min Age: 18Y None 30 30 ZONISAMIDE ZONISAMIDE 25MG CAPS None None 90 30 ZONISAMIDE ZONISAMIDE 50MG CAPS None None 90 30 ZONISAMIDE ZONISAMIDE 100MG CAPS None None 120 30 AEROCHAMBER PLUS FLOW- MISC Max Age: 20Y None 2 365 VU/SMALL MASK

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